20-21 Season Production Emergency Form

1
Name of Production(s)
2
Student Name* This field is required.
Prefix
First Name
Last Name
3
Pronouns* This field is required.
He/Him
She/Her
They/Them
4
Student Birthday * This field is required.
Date
Month
Day
Year
5
Student Grade* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
6
Parent/Guardian Name* This field is required.
First Name
Last Name
7
Parent/Guardian Name
First Name
Last Name
8
Primary phone number during rehearsal/performance * This field is required.
Area code
Phone Number
9
Secondary phone number during rehearsal/performance
Area Code
Phone Number
10
Persons to whom student may be released other than Parent/Guardian
Please enter their name and phone number
Please enter their name and phone number
Please enter their name and phone number
11
Pertinent and/or essential medication we should be aware of * This field is required.Please include any allergies and other condition you feel it's important for us to know.
12
Pertinent medical conditions we should be aware of, including any Covid-19 related considerations you would like to be aware of if you are in an immune-compromised household * This field is required.Please include any allergies and other condition you feel it's important for us to know.
Huge
Large
Normal
Small
Ok
Ok
13
Other personal informationPlease include any behavioral or psychological challenges your student maybe facing that you feel would be important for us to know. More information we have, better environment we can create to service your student. This information will be kept confidential and would be only shared with the director and the stage manager as needed.
Huge
Large
Normal
Small
Ok
Ok
14
Primary Physician Name* This field is required.
15
Primary Physician Phone* This field is required.
Area Code
Phone Number
16
Hospital
17
Parent consent: Medical* This field is required.It is the policy of Youth Theatre Northwest (YTN) to provide a safe and healthy environment for all students. Some of our activities involve group movement, stage sets and props. YTN takes measures to minimize potential hazards. However, these activities carry some unavoidable risk of injury or exposure to common communicable diseases. I have read the above statement and I give my permission for my child to participate in activities at YTN. I authorize YTN to act on behalf of my child in the event of an emergency and if my designated alternate or I cannot be reached, I wave and release YTN from any liability connected with illness or injury, which may arise in connection with his/her participation in YTN activities.
Yes, I agree.
18
Parent consent-Photo release* This field is required.Occasionally, YTN uses an artistic or photographic image of the actors who appear in our productions for promotional purposes. If your child's photo is used, their name (first name only) may or may not appear along with their image.
YES-YTN may use the image of my child in promotional materials with or without their name.
NO-YTN may NOT use the image of my child in promotional materials with or without their name.
19
Is your child allowed to walk/bike home?
YESNO
Should be Empty: