COVERED BRIDGE STUDIOS
Registration Form – Special Challenges Programs
Student or Parent -- Please fill out COMPLETELY & LEGIBLY; if needed to complete information use extra
paper; Form/Fee must be received byJune 2, 2009(unless arrangements are made with CBS)
PROGRAM Introduction To Acting & Improv
SEMESTER/DATES/TIMES Summer, 2009; Thursdays, June 4 through July 23; 6:30 to 8pm class;
Performance Thursday, July 30 – 6:30pm rehearsal and show from 7:30 to 8:15pm
STUDIO LOCATION Pioneer Grove Educational Center, 601 Willow Street, Frankfort, IL
(Lincolnway AreaSpecial Education Cooperative)
STUDENT’SNAME______M or F
SCHOOL______GRADE______AGE______
PARENT’S NAMES______
ADDRESS______CITY/STATE/ZIP______
HOME PHONE ______CELL PHONE______WK. PHONE______
PARENT’S EMAILS______STUDENT’S EMAIL______
ADDITIONAL EMERGENCY INFO & CONTACT (name/relationship/phone)______
______May we call an ambulance,
at your expense, if we are unable to reach the emergency contacts? Yes No please initial ____
HOW DID YOU HEAR ABOUT OUR PROGRAMS?______
WHAT ARE YOUR EXPECTATIONS/CONCERNS FOR THIS PROGRAM?______
______
PLEASE TELL US ABOUT THE STUDENT’S PHYSICAL/EMOTIONAL/PSYCHOLOGICAL CHALLENGES
______
DOES THE STUDENT HAVE A HISTORY OF SEIZURES? (explain)______
______
WHEN THE STUDENT IS UPSET, HOW DOES HE/SHE MANIFEST THIS AND WHAT DO YOU DO TO CALM HIM/HER?
______
IS THE STUDENT VERBAL OR NON-VERBAL?______DOES THE STUDENT HAVE SENSORY ISSUES?
IF SO, PLEASE DESCRIBE______
ARE THERE ANY COMMUNICATION, PROCESSING OR ATTENTION ISSUES WE SHOULD BE AWARE OF?
______
IS THERE ANYTHING ELSE ABOUT THIS STUDENT YOU WOULD LIKE US TO KNOW (including medical
info, medications, allergies, limitations, etc.)?______
PREVIOUS ACTING CLASSES & EXPERIENCES (go ahead, brag about yourself)______
______
OTHER NOTES/COMMENTS______
FEE $125 (please make checks payable to MY COVERED BRIDGE) Check Cash
WAIVER RELEASE OF ALL CLAIMS AND HOLD HARMLESS AGREEMENT
Read Completely
Please be aware that, in signing up and participating in this program, you will be waiving and releasing all claims for injuries arising out of this program that you or the named participant might sustain. The terms “I”, “me”, and “my” also refers to parents or guardians as well as students in the program. In registering for this program, you are agreeing as follows:
I recognize that there are certain risks of physical injury, and I agree to assume the full risk of any injuries, damages or loss which I may sustain as a result of participating, in any manner, in any and all activities connected with or associated with such programs.
I agree to waive and relinquish any and all claims I may have as a result of participating in these programs against Covered Bridge Studios, My Covered Bridge, Inc., Daniel Wm. DeWalt, VOICE-Advocacy, Pioneer Grove Educational Center, any and all other participating cooperating agencies, businesses or individuals, any and all independent contractors, officers, agentsand employees of the aforementioned organizations and individuals, and any and all other persons that might be directly or indirectly liable for any injuries that I might sustain while participating in this program.
I understand the nature of this program for which I am registering, and have read and fully understand this Waiver, Release and Hold Harmless Agreement. I further understand that any advisements or warnings of the particular risks of this program that I subsequently receive will be incorporated into and become part of this Agreement.
______
Parent or Guardian MUST sign if student is under the age of 18 Date
or still under the care of parent/guardian
______
Student MUST sign if 18 years or older Date
If mailing this form, please send it to:
Covered Bridge Studios
15058 Keeler Ave.
Midlothian, IL60445
Print out both sides (and make a copy for your records)
For additional information, please contact us at:
(708)371-5432 or
A separate form must be filled out for each student.
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(more on reverse side)