WORKSHOP REGISTRATION by X4apL3

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									                                        DREAMCOAT FANTASY THEATRE
                                                   SHOW REGISTRATION

                             “Mirror Image – A Real Enchanted Musical”
Please Print
First Name:_____________________________Last Name:___________________________
Address:____________________________________________________________________
      Street                         City                    Postal Code
Phone #:_________________________                              Date of Birth: _____ / _____ / _____
         Home                                                                  day month year
Other #:_________________________
(Identify)________________________                                      E-Mail:_____________________
Parent/Guardian Name:___________________________                        Relationship:____________________

Parent/Guardian Name:___________________________                        Relationship:____________________
School:______________________________________________________                                       Grade: _______
Have you been in a Dreamcoat Fantasy Theatre production before? No___ Yes___ Last Show__________
Health Card Number: __________________________ Allergies?:___________________________
Do you have any medical conditions or health concerns that we should be aware of? _____________
_____________________________________________________________________
Doctor’s Name: ____________________________ Doctor’s Phone No: ______________________
Emergency Contact: ________________________________________________________________________
                   Name                          Relationship            Phone No
Accident Waiver
I hereby covenant and agree to indemnify and save harmless the Dreamcoat Fantasy Theatre, (all officers, servants, agents, employees,
volunteers) with respect to any claim or demand arising out of any damages or injury caused by or arising from participation of the
applicant registered during any program in any facility or location where this program is being held.
______________________                                ___________________________
Parent / Guardian Name                                Signature

Publicity Release
I hereby give permission for pictures, press releases, and videos/DVD’s of my child to be used for publicity purposes by Dreamcoat
Fantasy Theatre and its productions. I understand any website photos will be group shots only.
______________________                                ____________________________
Parent / Guardian Name                                Signature

Privacy Regulations
I hereby acknowledge that in accordance with Federal and Provincial privacy regulations that Dreamcoat Fantasy Theatre will use the
above information for purposes directly related to the production of its shows or workshops. I understand that this information will not
be shared with any outside agency and that these forms will be destroyed following the final show or workshop presentation that my
child is participating in. I consent to Dreamcoat Fantasy Theatre retaining my name, my child’s name and age, my address, and my
phone number to be used in future to contact me for possible participation in related Dreamcoat presentations within the community.
______________________                                ___________________________
Parent / Guardian Name                                Signature

Please note that show fees are not refundable                  Pmt : Deposit $50.00                 Balance           100.00
                                                                     chq / cash                     chq / cash
                                                               Date: ____________                   Date: ____________

                                                               Confirmation Number:________________

								
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