CPAM Contact and Emergency Medical Acknowledgement Form

Actor Information and Parent/Guardian Consent Form
Actor's Full Name*

First NameLast Name
Actor's Full Name*
Birth Date*

MonthDayYear
Actor's Age*
School Grade*
School Grade*
Actor's E-mail
example@example.com
Actor's Phone Number
Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian Name 1*

First NameLast Name
Parent/Legal Guardian's Phone Number 1*
Format: (000) 000-0000.
Parent/Guardian E-mail 1*
example@example.com
Parent/Legal Guardian Name 2

First NameLast Name
Parent/Legal Guardian's Phone Number 2
Format: (000) 000-0000.
Parent/Guardian E-mail 2
example@example.com
Alternative Emergency Contacts
Contact 1*

Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation to Actor*
(Grandparent, Aunt, Uncle, Etc)
Phone Number*
Format: (000) 000-0000.
Contact 2*

Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation to Actor*
(Grandparent, Aunt, Uncle, Etc)
Phone Number*
Format: (000) 000-0000.
Medical Information
Family Physician's Name*
Family Physician's Phone Number*
Format: (000) 000-0000.
Preferred Medical Hospital*
Tylenol/AcetaminophenAdvil/IbuprofenNone
Allergies (food and medicine)Special Health Considerations (please include any health-mental or medical-conditions that we need to know about to ensure the safety of your child*
Type NONE if NONE

Medical Release

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
I agree to the above mentioned medical termsI do not agree to the above mentioned medical terms

MEDIA RELEASE

I give permission for my child’s picture to be used for publicity purposes by Children's Performing Arts of Miamisburg (CPAM). I understand that CPAM may videotape or photograph students cast in our production for use in flyers, publicity efforts, brochures, web use or other electronic communications or video usage.

Family members attending publicity programs, rehearsals and/or events may be included. All photos and videos are for CPAM use only and are the sole property of CPAM. I also understand that any photographs or videos taken by non-CPAM production/staff members must be approved by the CPAM Production Staff BEFORE being posted on any social media in order to protect the privacy and propriety of students, staff members and the overall production.

CONTACT INFO RELEASE

I give permission for my contact information (home address, phone number and email address) to be provided and/or released on an as needed basis for the care of students, schedule changes, rehearsal announcements and in the event of an emergency. This information will be in the possession of a CPAM production/staff member and will not be released outside of required circumstances. CPAM must be notified in writing if contact information can no longer be used.
I acknowledge that I have read the above mentioned Media and Contact Info Release statements

DISCIPLINE/HARASSMENT POLICY

CPAM takes incidents of bullying or harassment (verbal or physical) very seriously. No actor in any part is immune to disciplinary actions.

Any incidents of bullying, inappropriate touching or any type of harassing behavior should be reported immediately to the President of CPAM (or a Board Member) and a member of the artistic staff (Director, Stage Manager or Vocal Director). A “Two Strikes” policy has been implemented for disciplinary incidents requiring contact with the parents of a participant.

The first incident in which Staff must contact the parent(s)/guardian(s) of a participant will require the participant to be immediately picked up from rehearsal. No discussion with Staff will occur at this time (other than to sign out the participant) in order to avoid further interruption of rehearsal; however, Staff will discuss with the parent(s)/guardian(s) within 24 hours the disciplinary incident which has occurred. A second incident requiring Staff to contact the parent(s)/guardian(s) of a participant will result in a permanent dismissal from the production.

Parents/Guardians should report any issues to CPAM immediately without concern over retaliation.
I acknowledge that I have read the above mentioned Discipline/Harassment Policy section

Show T-Shirt Size: (Cotton t-shirt)*
Shirts will be available for purchase later in the show process
Pant Size*
Will be used for costuming
Additional Comments for the Production/Artistic Staff
Include any information that you believe is important for us to know
Parent/Guardian Signature - Sign to acknowledge that the information filled out within this form is accurate and you have read the information provided

Clear
Printed name of Parent/Guardian*
Date Entered*

MonthDayYear
Should be Empty:

Actor Information and Parent/Guardian Consent Form