Bee and Blossom Reg Form

Dino Drama Workshop at Greenfield Public Library
Date

MonthDayYear
Date
Child's/Children's Information
Child's Name

First NameLast Name
Grade
Is there anything in particular we should know about your child to best support them in a group?
2nd Child's Name (if applicable)

First NameLast Name
Grade
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
Grade
Is there anything in particular we should know about your child to best support them in a group?
Is the child (children) above able to attend all four sessions at the library from 10 - noon (7/13, 7/14, 7/16, 7/17) and the performance at the Great Greenfield DinoFest on Saturday, July 18 from 10 - noon?
If “no” or “not sure” above, please help us understand your child’s availability below so we can plan accordingly. Note: if there are more registrations than spaces available, we will prioritize children who can participate in more sessions.
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.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Permissions
Please check all that apply

Participation Release: I give permission for my child/children to participate in Piti Theatre's Dino Drama Workshop. I understand that all physical exercise involves some risks. I assume all risks associated with participation in this program, including, but not limited to: falls, contact with other participants, the effects of weather, traffic, and other reasonable risk conditions associated with the program.. All such risks to my child/children are known and appreciated by me. I understand this informed consent form and agree to its conditions on behalf of my child. Further, I authorize the Piti Theatre Company faculty person(s) to provide emergency medical treatment of any injury or illness my child may experience including treatment by qualified medical personnel if they consider treatment necessary. This authorization is granted only if I cannot be reached and a reasonable effort has been made to do so, or in a life-threatening situation.
Cost

This is a free (library!) program :)
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 Dino Drama Workshop and DinoFest. 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 these 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

MonthDayYear
Date
Signature
Should be Empty:

Dino Drama Workshop at Greenfield Public Library

Child's/Children's Information

Permissions

Cost