Bee and Blossom Registration Form

I am Registering For

Theater & Nature Week OneTheater & Nature Week Two

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade

Physician's Name*

Physician's Number*

Is there anything in particular we should know about your child to best support them in a group?

Does your child have any allergies to foods, bee stings etc., chronic illness, or medical conditions? If yes, please describe. If you would like a staff member to administer an injection in case of a bee sting, be certain to provide written permission, instructions and a supply of unexpired medication.*

2nd Child's Name (if applicable)

First NameLast Name

Birth Date

MonthDayYear

Grade

Physician's Name

Physician's Number

Does your child have any allergies to foods, bee stings etc., chronic illness, or medical conditions? If yes, please describe. If you would like a staff member to administer an injection in case of a bee sting, be certain to provide written permission, instructions and a supply of unexpired medication.

Is there anything in particular we should know about your child to best support them in a group?

3rd Child's Name (if applicable)

First NameLast Name

Birth Date

MonthDayYear

Grade

Is there anything in particular we should know about your child to best support them in a group?

Physician's Name

Physician's Number

Does your child have any allergies to foods, bee stings etc., chronic illness, or medical conditions? If yes, please describe. If you would like a staff member to administer an injection in case of a bee sting, be certain to provide written permission, instructions and a supply of unexpired medication.

Parent/Guardian Information

Parent/Guardian Name (primarily responsible for child/children's schedule)*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

example@example.com

Primary Phone Number *

Please enter a valid phone number.

Secondary Phone Number *

Please enter a valid phone number.

2nd Parent/Guardian Name (if applicable)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

example@example.com

Primary Phone Number

Please enter a valid phone number.

Secondary Phone Number

Please enter a valid phone number.

Emergency Information

It is Piti Theatre Company practice to call parents and 911 in case of emergency. If you would like another procedure followed please indicate here.

Emergency Contact Name (If parent can't be reached)*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

Please check all that apply*

I give permission for my child/children to participate in Piti Theatre's Youth Troupe and Theater & Nature program. I understand that all physical activity involves some risk, and I assume full responsibility for any risks associated with my child’s participation in this program, including but not limited to: falls, contact with other participants, the effects of weather, traffic, and other reasonable risk conditions inherent to such activities. I acknowledge that these risks are known and appreciated by me. I have read and understand this informed consent form and agree to its terms on behalf of my child/children.Furthermore, I authorize Piti Theatre Company staff to provide emergency medical treatment for any injury or illness my child may experience. This may include treatment by qualified medical personnel, if deemed necessary, and is authorized only if I cannot be reached after a reasonable effort has been made, or in the case of a life-threatening situation.Emergency Treatment: In the event of an emergency requiring medical treatment, I give permission for my child/children to be treated at Baystate Franklin Medical Center.Photo Release: I give my permission for Piti Theatre Company to use photos or video clips of my child in any press, poster, Piti website, or other promotional materials developed to support this production/class/camp.E-mail Release: I give my permission to receive e-mail from Piti about programming

Informed Consent and Acknowledgement

I hereby give my approval for my childs/children's participation in any and all activities prepared by Piti Theatre during the Youth Troupe. In exchange for the acceptance of said child’s candidacy by Piti Theatre, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Piti Theatre. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child/children, I hereby waive all claims against Piti Theatre, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Bee and Blossom Registration Form

Child's/Children's Information

Permissions