EMERGENCY FORM
Student Name:__________________________________________________ Age:_______________________
Address:_______________________________________________________________________________________
Grade:_________________ School:_______________________________________________________________
Safety Release/ Permission:
I __________________________________________________ am enrolling my son/ daughter in the JTP Production “Godspell Jr.”. I understand the he/she will be supervised by JTP/ Servite High School staff members while engaging in theatre activities. I fully understand that there is an inherent risk when involved in theatre and the use of Servite Theatre Facilities or any other JTP location. I hereby release Servite High School, Junior Thespian Productions and all staff and personnel from liability.
Parent Signature:______________________________________________________Date:_________________
Parent Cell #: ( )_________________________ Evening #: ( )______________________________
Parent Cell #: ( )_________________________ Evening #: ( )______________________________
Parent E-mail:________________________________________________________________________________
I prefer to be contacted via (circle one) Cell # Evening # E-Mail
List any physical conditions which might affect your son/daughter’s involvement in theatre:________________________________________________________________________________________
Allergies?_____________________________________________________________________________________
Physician:_____________________________________ Physician Phone:____________________________
Preferred Hospital______________________________________
Should your son/daughter need emergency medical attention and you are unable to be immediately reached, please list another contact:
Name:________________________________________Relationship to Student:_____________________
Phone #: ( )__________________________________
If you are unable to pick up your son/daughter, your son/daughter may be released to: _____________________________________________________________________________________________
_________________________________________________________________________________________________
In the event that you are unable to come for your child within the first few hours after a major disaster, your son/daughter may be released to an adult familiar to him or her, at the discretion of Junior Thespian Productions staff.
Yes______________ No_______________
I give permission to Junior Thespian Productions to photograph my son/ daughter for rehearsal and production pictures which may be used on the website, cast picture, or professional DVD.
Yes______________ No_______________