Emergency Contact Form

Select Class *

Class Title *

Class Start Date *

Student Name *

First

Last

Parent/Guardian Name *

First

Last

Email *

Emergency Contact Phone Number for Week of Camp 1 *

Emergency Contact Phone Number for Week of Camp 2 *

Allergies *

Medications that need to be administered during week of camp. *

In order to best serve your student, list all physical, cognitive, medical emotional or learning needs we should know about *

I hereby agree to have my child(ren) take part in Stages Theatre Company’s Education Programming. In case of an accident, the staff will administer reasonable first aid, contact parents immediately, and take precautions to ensure the safety and well-being of my child. I agree to release Stages Theatre Company, the Robbinsdale School District, PIM, The Hopkins Center for the Arts, and their respective staffs from liability for any accident that may occur during the course of the program.* *

Stages Theatre Company has a professional photographer who may take photos and/or video during workshops, workshop presentations and classes for our archives and for use in future education program marketing in print, broadcasting and online (no names would be listed with photos/video). Please check the appropriate place below.* *

E SIGNATURE *

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Last

Typing your name in the box above serves as an electronic signature

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