D2D Writing/Performance Workshop Registration Form

Animal Farm - Writing and Performance Workshop

Fill out the form carefully for registration
Student Name

First Name Middle Name Last Name
Birth Date

Month Day 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
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Animal Farm - Writing and Performance Workshop