Performer's First Name
Performer's Last Name
Performer's Birthdate *
Performer's Birthdate
Performer's Grade *
Performer's Gender *
Volunteer Requirements *
Each family is required to volunteer approximately 30 hours with this production. If you would like to opt out of this volunteer requirement, you may do so by paying an additional $650.
Payment *
Upon completion of this form, you may submit payment for the $225 participation fee via PayPal/credit card. ($5 credit card fee will be charged to cover costs.) Payment may also be made via cash or check at auditions. All payments must be made prior to auditioning.
Primary Parent *
Primary Parent
I (we) the undersigned do hereby authorize representatives of Theatre in the Mountains (TIM) (such representatives to be directors or identified volunteeers of the Loma Prieta Community Foundation), to serve as agents for the undersigned to consent to any X-Ray exam, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the provisions of the Medicine Practice Act on the medical staff of any hospital licensed by the State of California whether such diagnosis or treatment is rendered at the office of said hospital or some other site. It is understood that this autorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physicican in the exercise of his/her best judgement may deem available. I (we) also understand and agree that TIM will not be held responsible for injuries that occur to self/child while attending or participating in TIM productions. This authorization shall remain valid for the duration of the participant's current registration with Theatre in the Mountains.

Parent Name
Primary Parent Phone # *
Primary Parent Phone #
First parent we'll contact in an emergency
Primary Parent 2nd Phone
Primary Parent 2nd Phone
Alternate Parent Name
Alternate Parent Name
2nd parent to call
Alternate Parent Phone
Alternate Parent Phone
Alternate Parent 2nd Phone
Alternate Parent 2nd Phone
I hereby release and consent to the use of the photographic image of my child/children for publicity purposes by Theatre in the Mountains. This release also authorizes permission for you or your performer to be photographed by any photographer assigned by Theatre in the Mountains. I further understand that I hereby agree to release any interest in or to hold Theatre in the Mountains or its agents harmless for any income received by Theatre in the Mountains as a result of any of the aforementioned containing the photographic image of my child/children. By entering initials below, you agree to the above
Emergency Contact *
Emergency Contact
Other than parent who can we reach in an emergency if we are unable to contact the registered parent. Entry of this name authorizes this person to pick up your child.
Emergency Contact Phone *
Emergency Contact Phone
Emergency Contact 2nd Phone
Emergency Contact 2nd Phone
Others authorized to pick up your child *
Other than the parents AND emergency contact listed above, are there others that can pick up your child. (Please enter then below if you have selected so.)
Please enter names and phones numbers for people (in addition to parents and emergency contacts listed above) who are authorized to pick up your child.
Child's Doctor *
Child's Doctor
Doctor's Phone *
Doctor's Phone
Medical Insurance Carrier Phone # *
Medical Insurance Carrier Phone #
Enter the subscriber Id of the insured
Please enter Group ID for subscriber
Please help us to keep your child safe by letting us know any health issues here.
Dentist's Phone # *
Dentist's Phone #
Conflicts? *
Does your performer have unchangeable conflicts?
Conflict Dates *
Select all the dates for which you have a conflict, even when the conflict is partial for the day
Please explain any conflicts checked above
Does your actor want a speaking role?
Please list any roles your actor is interested in.