Animal Farm - Writing and Performance Workshop
Fill out the form carefully for registration
Student Name
First Name
Middle Name
Last Name
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian E-mail
example@example.com
Mobile Number
Emergency Contact
Emergency Contact Number
Physician's Name
Physician's Phone Number
List all known medical conditions (including allergies to food or medications
List any and all over-the-counter and/or prescription drugs taken regularly
Medical Insurance (Not Required)
Policy Number
Medical information is needed in the event of an emergency and the parent/guardian cannot be reached. Marking the selection below will act as your signature & authorization for emergency medical care
I authorize such diagnostic, medical, and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury, by licensed emergency medical professionals.
I give permission for my child (listed on this application) to participate in the summer workshop occurring at the GEM/Hub at the Dayton Arcade and will provide transportation, waiving any transportation provided by the GEM/Hub
I authorize participation in the workshop and waive transportation provided by the GEM/Hub
I give permission and consent for my child (listed on this application) to allow photographs to be taken during Dare 2 Defy session activities. I further give permission and consent that any such photographs may be published and used by Dare 2 Defy/Dare 2 Inspire to illustrate and promote the workshop experience. I release Dare 2 Defy Productions from all claims, demands, and liabilities whatsoever in connection with above. Marking the selection below will act as your signature & authorization for show-related photographs
I authorize Dare 2 Defy/Dare 2 Inspire to utilize photos of my child for promotional or marketing materials
Submit Application
Clear Fields
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform