Choose Your Drama Club Choose Your Drama Club Program * – Select One – Jeffersontown Tuesday Center Stage (Grades 2-5) | Spring 2023 | $135 If your school has multiple drama clubs and some are not shown, registration for those programs has closed. Student Information Student Information Student’s First Name * Student’s Last Name * Student’s Gender * – Select One – Male Female Nonbinary Student’s Grade * – Select One – K 1 2 3 4 5 6 7 8 Student’s Homeroom Teacher or Team * Mailing Address * Mailing Address Address Line 1 Address Line 1 Address Line 2 Address Line 2 City City State – Select One – Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Parent 1 Information Parent 1 Information Parent 1 First Name * Parent 1 Last Name * Parent 1 Phone * Parent 1 Email * Your registration confirmation will be sent to this address Want to help our young actors with their performance? Yes, please contact me (Parent 1) about volunteering on performance day! Parent 2 Information Parent 2 Information Add Another Parent? Enter contact information for Parent 2 Parent 2 First Name Parent 2 Last Name Parent 2 Phone Parent 2 Email Want to help our young actors with their performance? Yes, please contact me (Parent 2) about volunteering on performance day! Dismissal and Emergency Contact Information Dismissal and Emergency Contact Information Dismissal After Drama Club * – Select One – Car Rider Aftercare/ CEP Walker Other Dismissal After Drama Club All students (including Walkers) must be picked up following drama club by an adult 18 years or older. The only exception is students attending Aftercare/ CEP, who will be escorted to their program by Drama by George staff. Adults Authorized to Pick Up Child We will only release your child to an individual listed here or to the parent(s) named above. Medical Conditions or Allergies * Type “none” if not applicable Emergency Contact Name * If possible, please list someone who does not live in the same household as the student Emergency Contact Phone * Parent Permission Form Parent Permission Form How would you like to sign? I want to use an electronic signature Uncheck the box to download and sign the Parent Permission Form on paper Sign on Paper You have chosen to sign a paper form and mail it to Drama by George. Please download and print the PDF provided here. PLEASE READ CAREFULLY–THIS IS A LEGAL DOCUMENT. LIABILITY RELEASE. I, the parent or legal guardian of the minor child named above, understand that there are risks inherent in my child/ ward’s participation in this drama club/ drama camp sponsored by Drama by George LLC, which is scheduled to be held at the School or Hosting Organization I have selected above during the academic semester specified. The risks to my child/ ward may include, without limitation, personal injury and the loss of personal property. I hereby agree to release, indemnify, and hold harmless Drama by George LLC and the School or Hosting Organization; together with their directors, members, partners, employees, contractors, volunteers, agents, and assigns; from any and all claims which I or my child/ ward may have for any losses, damages, or injuries that are in any way related to my child/ ward’s participation in the drama club/ drama camp. PERMISSION TO USE PHOTOGRAPHS AND RECORDINGS. I grant permission for photographs, video recordings, and/ or audio recordings (“Content”) to be made of my child/ ward during the term of his/ her participation in the drama club/ drama camp. I hereby grant permission for Drama by George LLC and the School or Hosting Organization to use Content depicting my child/ ward in perpetuity, in all forms and media, for creating an publicly-accessible online media gallery from the drama club/ drama camp, for promoting future drama activities, and for any other lawful purpose. I understand that my child’s Content is not guaranteed to appear in an online gallery or to be publicly exhibited in any way. I waive any right which I or my child/ ward may have to inspect or approve the Content prior to its use. Note: If you do NOT wish to grant permission for your child to be photographed and/ or recorded, DO NOT SIGN THIS FORM. Contact us for further information. AGREEMENT TO POLICIES. I agree to be bound by Drama by George LLC’s Registration and Payment Policies, which are hereby incorporated into this document by reference. ELECTRONIC SIGNATURE. I have chosen to execute this legal document with an electronic signature. I intend my electronic signature to have the full force and effect of a handwritten signature for the purposes of validity, enforceability, and admissibility. Signature * Clear Use the mouse or your finger to sign in the box Type your full legal name * Payment Information Credit Card * Credit Card Billing Address * Credit Card Billing Address Address Line 1 Address Line 1 Address Line 2 Address Line 2 City City State – Select One – Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip If you are human, leave this field blank.
