Education Sign Up - The Cape Playhouse

Name of Student: *

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Last

Student Date of Birth: *

Parent/Guardian Name: *

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Last

Parent/Guardian Phone:

E-Mail: *

Address: *

Week of Enrollment *

Emergency Contact *

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Last

Emergency Contact Phone: *

Student's Physician: *

Physician Phone: *

Allergies: *

Current Medications: *

Restrictions (if any): *

By checking, I give permission to The Cape Playhouse staff to administer basic first aid to my child. I also give permission for The Cape Playhouse staff to seek emergency medical treatment. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by The Cape Playhouse staff to secure and administer treatment for my child. *

Agree
Disagree

The Cape Playhouse takes every precaution in order to guarantee your child's safety while participating in our programs. It is understood that neither The Cape Playhouse, nor any of its employees can be held responsible for any incidents resulting in injury due to negligence on the part of the student, parent or guardian. *

Agree
Disagree

The Cape Playhouse has permission to use my child’s photograph publicly to promote and market the theatre and the theatre’s educational programming. I understand that the images may be used in print publications, online publications, websites, and social media. I understand that no royalty, fee or other compensation shall become payable be result of such use. *

Agree
Disagree

How did you hear about us? *

Any additional information:

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