Constellation Stage & Screen Youth Scholarship Application Form

Please complete the form below to apply for a youth scholarship. Scholarships are processed in the order they are received and we will either reserve a spot or follow up regarding availability at that time. Once we verify eligibility, your registration will be confirmed via email. Registrations are processed in order they are received. See full Youth Scholarship Program details here.

Please list the class or camp and the starting date for which the participating student is applying:

Full Name

First NameLast Name

Birthdate

Date

Current grade (upcoming grade if registering for a summer camp)

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Authorized Pick-ups: Please list anyone authorized to pick up your child (Photo ID required at pick-up each day).

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Emergency Contact (Optional)

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please detail any health or medical concerns of which we should be aware, if applicable:

For Constellation Stage & Screen programs there is a limit of one scholarship per child per term (there are three terms each year: Fall, Spring, and Summer). Scholarships cover a single course’s fee, apply to a single class, and cannot be split between classes. Applicants who qualify will have the scholarship applied automatically. You will not be contacted unless there are questions regarding the status of scholarship verification. Verification may happen after program starts. If your child does not qualify you will be responsible for the full cost. Please contact us in advance with any questions.

Verification ~ I authorize my child's school district to verify eligibility. Constellation Stage& Screen program representatives will contact your school district to verify your eligibility. Home school and alternate schooling circumstances may necessitate proof of income on a federal tax return to verify eligibility. (Write in school district below)

For home school or alternate schooling circumstances, please attach proof of household income to verify eligibility, which is based on Indiana's household income requirements for free or reduced lunches with the National School Lunch Program (information here). For example, recent pay stub(s), employer attestation, documentation of participation in an income-based government program, or your most recent tax return (Form 1040).

Release of Information
By my signature below, I authorize Constellation Stage & Screen (hereafter referred to as Provider) to release medical information regarding the above-named minor/student to any person or entity to whom Provider refers the minor/student for emergency medical treatment.

Permission for Treatment and Release
The health history provided on this form is correct to the best of my knowledge. By my signature below, I hereby grant permission and authorize the provision of emergency medical treatment for minors/students who become ill or injured while participating in a Provider-sponsored Program. Should an emergency arise while my child is under the supervision of the staff of Provider, I do hereby authorize the staff to obtain and/or provide emergency medical attention for my child. I acknowledge and understand that Provider does not provide medical insurance to cover medical care for my child and that in the event of an injury requiring medical care, my personal health insurance will be responsible for payment of all medical care. I do hereby give consent to the administration of an emergency prescription medication (i.e. Epipen) prescribed to the above named minor/student where I have provided written instruction. I do hereby release and forever discharge Provider and its employees, volunteers, agents, officers, trustees, affiliates and representatives from any and all liability of any kind for any claim, demand, action, cause of action, expense, judgment or cost, including without limitation attorney’s fees, which arise out of or relate in any manner to the exercise of authority or judgment pursuant hereto, or to the securing, oversight, administration or supervision of medical or other care or treatment on behalf of my child at any time or any travel incident thereto.

Assumption of Risk
I acknowledge, understand and appreciate that as part of my child’s participation in Provider programs or activities there are dangers, hazards and inherent risks to which my child may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further realize that participating in the programs or activities may involve risks and dangers, both known and unknown, and have elected to allow my child to take part in the programs or activities. Therefore I, on behalf of my child, voluntarily accept and assume all risk of injury, loss of life or damage to property arising out of participating and traveling to or from the programs or activities.

Release and Waiver of Liability
In consideration of participation in Provider programs or activities, I do hereby agree for myself and my heirs, assigns, personal representatives, executors and administrators, to waive, release, and forever discharge Provider and its respective directors, officers, employees, representatives and members (the “Releasees”) from liability for any loss or damage and from any rights, claims or demands therefore which I have or which may hereafter accrue to me arising out of injury to my child or loss of my property incurred in connection with my child’s participation in Provider programs or activities, whether such damages are caused by the negligence of the Releasees or otherwise.

Immunizations
By signing below, I acknowledge that the participating student has been immunized in accordance with the Indiana Department of Health's immunization requirements for children and teens.

Audio-Visual Waiver
I understand that my child may be photographed or videotaped during their participation in this activity and consent to the reproduction of such photos or videos for advertising and publicity purposes.

Authorized Pickups/Emergency Contacts
All listed as authorized pickups/emergency contacts may be contacted in the case of an emergency and are authorized pick-ups. I acknowledge that anyone authorized to pick up the participating student will show photo ID at each sign-out.

By signing my name the box below and submitting this form I acknowledge that I have read this release and understand all of its terms and by submitting I am electronically signing it voluntarily and with full knowledge of its significance.

Date

Signature of Legal Guardian

Constellation Stage & Screen Youth Scholarship Application Form

Student Information

Parent/Guardian Information

Authorized Pick-ups and Health Information

Scholarship Limits and Eligibility

Eligibility Documentation