2022-2023 First Act Medical/Photo Release & Conduct Form

2022-2023 First Act Medical/Photo Release & Conduct Agreement

***Students without this contract will not be eligible to stay at classes, camps, rehearsals, or productions until all forms are submitted.***
I give permission for my child,*

First NameLast Name
To participate in First Act Theatre Arts 2022-2023 activities (August 1, 2022 through August 1, 2023)*

Yes
Parent/Guardian Name*

First NameLast Name
Cell Phone Number:*

Area CodePhone Number
Primary E-mail*
Emergency Contact:*

First NameLast Name
Emergency Contact Phone:*

Area CodePhone Number
Insurance Company Name:*
Policy # or Member #:*
Primary Care Physician:*
Physician Phone:*
Allergies:
Food Sensitivities/Dietary Restrictions:
Medical/Behavioral Conditions:
Special Needs:
Is your student currently part of the HEART Program (First Act's inclusion program for students with developmental and physical disabilities), or would you be interested in someone contacting you with more information about the HEART Program?*

Already part of HEARTInterested in being contacted about HEARTDoes not apply or not interested
Medical Release

The undersigned, the parent or legal guardian of the above-named minor, grants permission of the above-named minor to participate in classes, camps and other activities provided or sponsored by First Act Theatre Arts. The undersigned understands and acknowledges that the above-named minor may suffer injury, sickness or other physical harm from participating in such activities. The undersigned further understands that the undersigned is responsible for all costs and charges for medical treatment that may result from such injury or sickness, or other damages that otherwise result, relate to or arise from participation in the First Act activities.

The undersigned further understands and acknowledges that First Act Theatre Arts will not allow the undersigned or the above-named minor or immediate relatives thereof to participate in the First Act activities without releasing and holding First Act Theatre Arts harmless. The undersigned requests that First Act Theatre Arts. allow above-named minor to participate in the First Act activities, and in consideration thereof, agrees to release First Act Theatre Arts from all actions, causes of action or claims for damage of any kind growing out of or relating to any of the First Act activities in which the undersigned or above-named minor or their immediate families participate. The undersigned acknowledges that this is a full and complete release of all injuries, sicknesses and damages that the undersigned or above-named minor or their immediate families may sustain or incur as a result of participation in the First Act activities.
Yes,*

I have read and understand the Medical Release.
Photo Release

The undersigned gives permission to First Act Theatre Arts to use any and all photographic portraits or pictures, television spots, movie films, video tapes, websites and/or sound recordings, or any part thereof, taken or created during the First Act activities (which may include the undersigned and/or above-named minor and/or their immediate families) in promotional materials.
Yes,*

I have read and understand the Photo Release.

2022-2023 First Act Medical/Photo Release & Conduct Agreement

First Act Theatre Arts Code of Conduct