SpringStage Registration
Name *
Name
Mother's/Guardian's Name *
Mother's/Guardian's Name
Father/Guardian's Name *
Father/Guardian's Name
Home Phone Number *
Home Phone Number
Address *
Address
Mother's Cell Number *
Mother's Cell Number
Mother's Work Number
Mother's Work Number
Father's Cell Number *
Father's Cell Number
Father's Work Number
Father's Work Number
Costume Measurements
Emergency Contact Home Phone Number *
Emergency Contact Home Phone Number
Emergency Contact Cell Phone Number *
Emergency Contact Cell Phone Number
In the event of an accident or illness, Young Actors Studio, LLC will make every effort to contact and inform a parent. I hereby provide facts regarding my child's medical history, including medication, allergies, and any physical impairment to which a physician should be alerted (if nothing, please type "nothing"): *
Consent to Treat *
Consent to Treat By checking this box, I give my consent for emergency care prescribed by an adult licensed physician, dentist, or other qualified medical personnel acting under their supervision. This care may be given under whatever conditions are necessary to preserve life, limbs, and well being of my dependent. I give consent for treatment. *
Participation Waiver *
By checking the box below, I acknowledge and understand that as a condition to enrolling in the programs offered by Young Actors Studio, LLC, an Ohio limited liability company, the undersigned participant, or if the participant is under eighteen (18) years of age, the undersigned parent or guardian of the participant does hereby acknowledge and agree: That I assume and /or assume on behalf of my child or ward, all risk of injury, both known or unknown, or loss incurred at or arising out of the participation in programs offered by Young Actors Studio, LLC, its members, managers, employees, agents, successors and assigns form and against any and all claims, actions, demands, costs or expenses, including but not limited to claims for bodily injury, wrongful death, theft or property damage arising directly or indirectly out of or relating to participant’s enrollment in programs and activities offered by Young Actors Studio, LLC. I agree to the terms and conditions of the Participation Waiver. *
Publicity Release Agreement *
By checking the box below, I acknowledge and understand that without any compensation or notification to, or approval by the undersigned or participant, the participant's name, photograph, video, audio and biographical information may be used, reproduced or otherwise be disseminated or published by or on behalf of Young Actors Studio, LLC for any purpose, including, but not limited to, advertising and/or promotion of Young Actors Studio, LLC. I agree to the terms and conditions of the Publicity Release Agreement. *