Theatre 1 (7th -12th Grade Homeschool) Intake Form

Student Intake Form

Anchor Academy Programming - Homeschool Theatre 1
Student Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday

MonthDayYear
Date
Email (if applicable)
example@example.com
Parent/ Guardian Information
Name

First NameLast Name
Address (if different from student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Daytime Phone Number
Please enter a valid phone number.
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Health Information
Please list any medical conditions our staff should be aware of while your child is in our care/class including any diagnosed conditions, diagnosed or undiagnosed mental health disorders, etc :
Please list any allergies (food or otherwise) that we should be aware of while your child is in our care/class:
Recommended Skills for Success in Theatre I

To ensure students are able to participate fully and safely in this course, we recommend that students entering Theatre I possess the following foundational skills. These are not intended to exclude participation but to help families assess readiness for the pace and structure of the class:
Academic & Communication Skills:
- Ability to read scripts and class materials at a 7th-grade level or higher
- Ability to write brief reflections, notes, or character work independently or with minimal support
- Ability to follow multi-step directions (written and verbal)
- Willingness to engage in group discussions and collaborative projects
Physical & Sensory Skills:
- Ability to participate in light physical activity such as walking, basic stage movement, and group blocking
- Ability to engage in basic gross motor tasks (e.g., crossing stage, standing/sitting on cue, expressive gestures)
- Ability to manage fine motor tasks like writing, holding a script, typing papers or simple prop handling
Social & Behavioral Readiness:
- Ability to work cooperatively in pairs and groups
- Ability to sustain attention and focus during class activities
- Willingness to try new activities in a supportive, encouraging environment
Accommodations & Support:
If your student would benefit from support in any of these areas, please let us know in advance! We are happy to discuss accommodations that may allow your student to thrive within the class structure. Please note that the ratio for this class is 1:16.
Please check the box indicating that you have read and understand the Recommended Skills for Success*

I have read the Recommended Skills for Success and believe this class is a good fit for my student at this time. I understand I may contact the instructor to discuss any supports or questions.
The Mill at Lebanon / Restrooms Policy

The Mill at Lebanon is a public, multi-use space. There is not a restroom in our studio. There is only ONE restroom upstairs, where our studio is located, and it is only a one stall facility. There are public restrooms downstairs, open to both students and the general public. Since the class is only 90 minutes long, it is not feasible to take a collective restroom break as a group every time a child has to use the restroom throughout the class period. There is only 1 teacher per 16 students for this course. Therefore students will be allowed to leave the classroom to use the restroom only after "checking out" with the instructor. Students may take another student (of the same gender) to accompany them to the public restroom downstairs or upstairs restroom (remaining outside in the hallway). There are several classes happening at Anchor Academy at the same time as Theatre 1 and many children present throughout the facility, however, in respect to safety, Stage Local felt it is important to notify parents of the public nature of the facility and restroom policy.
Please check the box indicating that you have read and understand the Restroom Policy for Stage Local's Theatre 1 Class:*

I have read the above Restrooms Policy and consent to my child walking to and from the public restrooms at The Mill at Lebanon accompanied by another student of the same gender OR as a group accompanied by the instructor.
Attendance & Course Commitment

Theatre I at Stage Local is designed to be a year long course broken into two semesters (Fall and Spring). Tuition is due MONTHLY. However, students must commit to a semester at a time. The Fall 2025 semester runs from August - December. Please fill out the statement and sign below.
My child (Child's Name Here)* commits to attend the Fall Semester of Theatre 1 at Stage Local Lebanon running from August 2025-December 2025 following the course calendar set by Stage Local Lebanon. I (Parent's Name)* understand that tuition is due monthly and is non-refundable regardless of whether or not the class meets (due to weather, sickness, planned break set forth by school calendar, or extenuating circumstance). I (Parent's Name)* also understand that course tuition is due each month and is non-refundable whether or not my child attends the course, or actively participates in the course. Students may not be pulled from the course mid-semester without contacting the instructor for approval.
Parent Signature*

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Dismissal

Please indicate how your child should be dismissed in the afternoon, and the first and last name of the person(s) your child may be released to at dismissal. This only applies to students who DO NOT attend Anchor Academy and do not follow the Anchor Academy dismissal procedures.
My child:*

Does not drive and will be picked up via sign-out at the Stage Local studio by one of the individuals listed below.Drives and may leave Stage Local Studio independently at dismissal.Is a Student at Anchor Academy and will follow dismissal procedures set forth by Anchor.
Name

First NameLast Name
Name

First NameLast Name
Fine Arts Credit Information
Stage Local's Theatre I class is an informational, enrichment course for homeschool students. It is designed to count for course credit for Anchor Academy students only and is not accredited by any other service, nor affiliated with the State of Tennessee to count as a high school credit course otherwise. It is up to each parent and each student's individual homeschool "umbrella" programming as to whether or not the material taught in this course may count for the fine arts credit needed for graduation.
Please check the box indicating that you have read and understand the high school credit information regarding Stage Local's Theatre 1 Class:

I understand that Stage Local's Theatre I class is an informational, enrichment course for homeschool students designed to count for course credit for Anchor Academy students only and is not accredited by any other service, nor affiliated with the State of Tennessee to count as a high school credit course otherwise. I understand it is up to each parent and each student's individual homeschool "umbrella" programming as to whether or not the material taught in this course may count for the fine arts credit needed for graduation.
Liability Release / Health Care Authorization
RELEASE AND WAIVER: The undersigned understands that participation in Stage Local Lebanon events and productions will expose participants to activities and equipment which can cause accidents and injuries, and that participants will not be supervised outside of rehearsal or class time. The undersigned acknowledges receipt of the “Conditions of Participation” and agrees to abide by the requirements contained therein. In consideration of the participant’s acceptance into Stage Local programming, that the undersigned does hereby release, waive, discharge, indemnify, and hold harmless Stage Local , its directors, officers, employees and agents, from and against any claim for damage, injury, loss or death to the above named participant resulting from participation in any class, program, play or other activity either at Stage Local Studio at The Mill at Lebanon or at another location, including any damage, loss or injury resulting from failure to abide by the “Conditions of Participation.”

HEALTH CARE AUTHORIZATION: The undersigned hereby authorizes Stage Local Lebanon employees to do any acts which may be necessary or proper to provide emergency health care of any student in the event that the Parent/Guardian cannot be reached, including consent to and authorization of medical procedures by physicians, dentists, hospital or other emergency medical personnel, as they, in the exercise of their sole discretion, may deem necessary. The undersigned understands that (s) he is responsible for all costs and expense of such medical treatment.

PHOTO/VIDEO/AUDIO AUTHORIZATION: The undersigned parent/guardian understands that the above named student could be featured in photography or videography associated with Stage Local programming and hereby grant permission to take pictures and recordings of class/performances for publicity and promotional purposes (website, publications, etc.).

I HAVE READ THE ABOVE WAIVER AND RELEASE LIABILITY AND BY SIGNING, I AGREE THAT IT IS MY EXPRESS INTENT TO EXEMPT AND RELIEVE STAGE LOCAL LEBANON AND ITS EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY OR WRONGFUL DEATH OTHER THAN CLAIMS THAT RISE AS THE DIRECT RESULT OF ACTIVE OR FORESEEABLE NEGLIGENCE. I CERTIFY THAT I HAVE FULL AUTHORITY TO SIGN THIS RELEASE AND AUTHORIZATION.
Signature*

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Tuition Payment
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Theatre 1 - August Tuition August tuition for Theatre 1 - Homeschool Class.
$100.00

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Student Intake Form

Student Information

Parent/ Guardian Information

Emergency Contact

Health Information

Recommended Skills for Success in Theatre I

The Mill at Lebanon / Restrooms Policy

Attendance & Course Commitment

Dismissal

Fine Arts Credit Information

Liability Release / Health Care Authorization