The Arts Partnership of Greater Hancock County Youtheatre Program MEDICAL INFORMATION AND EMERGENCY CONTACT INFORMATION *Only one per student needs to be filled out. * Only need one on file per fiscal year

Youth Name:_______________________________ Address:_____________________________

Home Phone:________________________ City:__________________ State:______

Parent/Guardian Name:_______________________________ Home Phone:________________________ Relationship to Youth:_________________ Work/Mobile Phone:________________________ Address:_____________________________ City:__________________ State:______ Secondary Contact Name:_______________________________ Home Phone:________________________ Relationship to Youth:_________________ Work/Mobile Phone:________________________ Address:_____________________________ City:__________________ State:______ Insurance Information Insurance Provider Name:_______________________________________________________ Primary Policy Holder:_______________________ Relationship:_______________________ Group Number:_______________________________ Plan Number:_________________ Primary Physician Name:_______________________________ Address:_____________________________

Phone:_____________________________ City:__________________ State:______

Dentist Name:_______________________________ Address:_____________________________

Phone:_____________________________ City:__________________ State:______

Allergies or Medical Problems (please be sure to list any food, medication, or other substance that may contribute to allergic reactions) __________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Current Prescriptions____________________________________________________________ _______________________________________________________________________________ Medical Consent I understand that there are some risks inherent in the activities that are included in the Program, but willingly assume these risks in order to allow my child to participate. If I cannot be reached in the event of an emergency, I give permission for any care or treatment by a physician, surgeon, hospital, nurse, doctor's assistant, or medical care facility that may be required.

 In case of an emergency, and I cannot be reached, I DO give permission for care or treatment as outlined above.

 In case of an emergency, and I cannot be reached, I DO NOT give permission for care or treatment as outlined above. An adult or guardian MUST attend all rehearsals and events. 3

The Arts Partnership of Greater Hancock County Youtheatre Program PARTICIPATION, RELEASE, AND CONSENT FORM

Permission to Participate I, the undersigned, am the parent and/or legal guardian of the below identified child. By and through my signature affixed below, I do hereby give my authorization and consent for my child to participate in the Youtheatre Program sponsored by The Arts Partnership of Greater Hancock County. Further, I agree to release and hold harmless The Arts Partnership of Greater Hancock County, its Board of Directors, agents or volunteers, The Marathon Center for the Performing Arts, its Board of Directors, agents or volunteers and the First Presbyterian Church of Findlay against any liability, loss, damages and/or expense, in law or equity, by any person or persons resulting from the administration, performance, planning, preparation, development, conduct, and execution of the Youtheatre Program. I understand that my child will participate in the Youtheatre Program from January 9, 2017 through February 26, 2017. With advanced notice, these times and dates may be adjusted. Measuring for Costumes I understand that my child will be measured for his or her costume on Monday, January 9 during the read through. I give Youtheatre volunteer’s permission to measure my child for his or her costume. I do not give Youtheatre volunteer’s permission to measure my child. Therefore, I will be present to assist when my child is being measured on January 9, 2017.

Photograph and Video: I fully understand that my child may be included in photos or videos for promotion of the program or production or for archival purposes. I also understand that my child might be in contact with the press prior to the performance or at an opening event or exhibition. Also, it may be necessary for program staff to photograph or videotape participating youth for purposes other than promotion. I give permission for program staff to photograph or videotape my child and include my child in photographs or videos utilized by The Arts Partnership for its legitimate purposes, including, but not limited to, public purchase and organizational/event promotion.

I HAVE READ, FULLY UNDERSTAND, AND AGREE TO THE INFORMATION ABOVE.

Name of participant

Signature of Parent or Guardian

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Date

The Arts Partnership of Greater Hancock County Youtheatre Program CONFLICT LIST Alice in Wonderland Jr. Winter 2017 We will rehearse Monday-Thursday evenings. Additional schedule information will be presented at the initial parent meeting. Attendance by each participant is expected at the rehearsals when he/she is scheduled. In the event of any schedule conflicts, they need to be listed on this form and submitted at auditions for approval by the production team. Please list all school functions, music lessons, sports, church, and community activities, family vacations, etc. After the list has been approved, any necessary changes must be approved in advance by the production team. Any unexcused absence may result in a change in a participant’s role in the production or participation in choreographed numbers. Even though only selected on-stage cast and technical crew members may be scheduled for some of the early rehearsals, please note that ALL on-stage cast members MUST attend the runthrough/technical rehearsals during the last 2 weeks of rehearsals. Please list any weekly conflicts: Mondays _______________________________________________________________________ Tuesdays _______________________________________________________________________ Wednesdays _____________________________________________________________________ Thursdays _______________________________________________________________________ Fridays _________________________________________________________________________ Saturdays _______________________________________________________________________ Sunday afternoons ________________________________________________________________

Please list any one-time conflicts: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

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PHOTO RELEASE AND BEHAVIOR STANDARDS MINOR PARTICIPANT PHOTOGRAPH, IMAGE and/or NAME RELEASE POLICY Youtheatre will occasionally use photos from our events in our publicity material, including, but not limited to, our website, Facebook, brochures, etc. Please choose whether or not you authorize Youtheatre to use your child’s photo as “publicity/performance record.” I/We do authorize the release of my/our child’s photograph, image and/or name as “publicity/performance records”. I understand that a record of this request will be filed electronically at the Arts Partnership office and his/her photograph, image or name may be used in theater publications or other methods of information dissemination under the control of The Arts Partnership. I/We do not authorize the release of my/our child’s photograph, image and/or name as “publicity/performance records”. I understand that a record of this request will be filed electronically at the Arts Partnership office and his/her photograph, image or name may not be used in theater publications or other methods of information dissemination under the control of The Arts Partnership.

BEHAVIOR STANDARDS We’re happy you’re here! Please follow these guidelines for all Youtheatre events:       

Be kind and respectful to participants and instructors! Listen and follow directions! Obey rules! Demonstrate a positive attitude! Be prompt on arrival and departure! Show respect for your environment and the theater! Most importantly……Have Fun!!

Disrupting the learning environment and/or inappropriate behavior can be cause for dismissal from the program. Any participant that behaves in a manner that is inconsistent with expectations will be spoken to immediately by the education director, parent volunteer, teacher, teaching assistant or The Arts Partnership board member. If no change of behavior is evident, the participant’s parent or guardian will be notified. If necessary, the child will be dismissed from the theater, camp or class and a refund will not be issued. Parent or guardian: Please list all participating children’s names:

has/have read and will comply with Youtheatre’s Photo Release and Behavior Standards.

Parent or Guardian signature

Date signed

Created 7/2015