Student Name *

First Name

Last Name

Student Cell (if they have one)

(###)

###

####

Parent/Guardian Name *

First Name

Last Name

Home Phone

(###)

###

####

Parent/Guardian Cell Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will you accept any role offered to you?

Yes

No

If not cast, will you be interested in being on the TECH CREW (if we have one)?

Yes

No

Please check boxes(s) that may interest you on the BACKSTAGE CREW:

Stage Crew

Props

Costumes

Lights

Sound

Paint

Construction

Riverside Theatre for Kids - Parental Authorization *

I hereby waive and release any and all claims for damages, injuries, or death that may be suffered before during or after activities with Riverside Theatre. I will further hold harmless Riverside Theatre. I hereby authorize any physician, trainer, or nurse selected by Riverside Theatre personnel to order and contact any emergency medical or surgical procedures necessary to save life and limb. I understand and give permission for my child to be filmed and photographer for print and Internet publication and archives. I acknowledge that my child will abide by Riverside Theatre rules and regulations.

Parent/Guardian agrees to this policy

Email Student Photo For Program To: kevinq@riversidetheatre.com

Emailed