Performer's Birthdate *

MM

DD

YYYY

Performer's Grade *

3rd Grade

4th Grade

5th Grade

Performer's Gender *

Boy

Girl

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.

I would like to pay the $650 to "buy out"

I will volunteer approximately 30 hours

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.

Online with Credit Card or paypal (small fee applies, no account needed)

Check (owes $225)

Scholarship (or partial scholarship)

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

First Name

Last Name

Primary Parent Phone # *

First parent we'll contact in an emergency

(###)

###

####

Primary Parent 2nd Phone

(###)

###

####

Alternate Parent Name

2nd parent to call

First Name

Last Name

Alternate Parent Phone

(###)

###

####

Alternate Parent 2nd Phone

(###)

###

####

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.

First Name

Last Name

Emergency Contact 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.)

Listed Below

none

Child's Doctor *

First Name

Last Name

Doctor's Phone *

(###)

###

####

Medical Insurance Carrier Phone # *

(###)

###

####

Dentist's Phone # *

(###)

###

####

Conflicts? *

Does your performer have unchangeable conflicts?

Yes

No

Conflict Dates *

Select all the dates for which you have a conflict, even when the conflict is partial for the day

NO CONFLICTS

Sep. 8 (Tu)

Sep. 9 (W)

Sep. 10 (Th)

Sep. 14 (M)

Sep. 15 (Tu)

Sep. 16 (W)

Sep. 17 (Th)

Sep 21 (M)

Sep 22 (Tu)

Sep 23 (W)

Sep 24 (Th)

Sep 28 (M)

Sep 29 (Tu)

Sep 30 (W)

Oct 1 (Th)

Oct 5 (M)

Oct 6 (Tu)

Oct 7 (W)

Oct 8 (Th)

Oct 13 (Tu)

Oct 14 (W)

Oct 15 (Th)

Oct 19 (M)

Oct 20 (Tu)

Oct 21 (W)

Oct 22 (Th)

Oct 26 (M)

Oct 27 (Tu)

Oct 28 (W)

Oct 29 (Th)

Nov 2 (M)

Nov 3 (Tu)

Nov 4 (W)

Nov 5 (Th)

Nov 9 (M)

Nov 10 (Tu)

Nov 11 (W)

Nov 12 (Th)