Southwest Playhouse Inc. Student Liability Waiver & Release Form

Southwest Playhouse Inc. Student Liability Waiver & Release Form Student’s Name ________________________________________________ DOB_______________ Parent(s)/Guardian(s) ____________________________________________________________ Address _______________________________________________________________________ City _______________________________________ State _____________ Zip ______________ First Emergency Contact _____________________________________ Phone _________________ Second Emergency Contact ___________________________________ Phone ______________ Special Health Care Needs and/or Allergies ___________________________________________ ________________________________________________________________________________ RELEASE AND WAIVER I hereby give permission for the above named student to participate in Southwest Playhouse’s Camp Hakuna Matata. I declare that I am the parent or legal guardian of the above named child, and I have custody and control of the child. In the event my child is injured or should require medical attention, I hereby request that you contact me or our emergency contact. In the event that we cannot be reached, I hereby authorize Southwest Playhouse Inc’s representative(s) to secure necessary medical treatment for my child, including consent to and authorization of medical procedure by physicians, dentists, hospital or other emergency medical personnel, as they, in the exercise of their sole discretion, may deem necessary. I further acknowledge that I will be responsible for any medical or hospital fees or costs associated with my child’s medical treatment. I understand that participation in any programs at Southwest Playhouse Inc may expose my child to activities and equipment which could cause accidents and injuries; I further understand that my child will not be supervised outside of class time. I understand that as a participant, my child may be climbing on and off of stage and set pieces. I also understand that my child may be running, jumping, dancing and varied other movements on stage. I understand that my child may be running, jumping, dancing near moveable set pieces. I assume all risks and hazards to such participation including transportation to and from rehearsals and performances. I hereby waive, release, absolve and indemnify and agree to hold harmless, Southwest Playhouse Inc, its organizers, sponsors, supervisors, and participants from and against any claim for damage, injury, loss or death of my child (other than claims that arise as the direct result of active or forseeable negligence) resulting from participation in any class, program, play or other activity either at the Playhouse or at another location including any damage, loss or injury resulting from any failure to abide by the rules as explained to my child by Southwest Playhouse representative(s) upon onset of activity. With my child’s participation in Camp Hakuna Matata and/or Disney’s The Lion King JR, I grant permission to take pictures and recordings of class/performances for publicity and promotional purposes (website, publications, etc.). MY SIGNATURE INDICATES THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF THE ABOVE WAIVER & RELEASE FROM LIABILITY. I CERTIFY THAT I HAVE FULL AUTHORITY TO SIGN THIS WAIVER & RELEASE FROM LIABILITY. Parent/Guardian (signature) ________________________________________ Date _____________ * Disney’s The Lion King JR Is presented through special arrangement with Music Theatre International (MTI). All authorized performance materials are also supplied by MTI. www.MTIShows.com. Music and Lyrics by ELTON JOHN & TIM RICE. Additional Music and Lyrics by LEBO M, MARK MANCINA, JAY RIFKIN, and HANS ZIMMER. Book by ROGER ALLERS & IRENE MECCHI. Based on the Broadway production directed by Julie Taymor. Music Adapted & Arranged and Additional Music & Lyrics and “Luau Hawaiian Treat” written by Will Van Dyke. “It’s a Small World” written by Richard M. Sherman and Robert B. Sherman. Southwest Playhouse Inc. Student Permission & Enrollment Form Student’s Name__________________________________________ Sex M / F Age __________ Grade (as of 2019/2020 School Year) __________ School Attending _____________________________ T-Shirt Size (circle your size, youth and adult sizes available) YS YM YL YXL AS AM AL AXL Parent/Guardian Home Phone _____________________ Cell Phone ______________________ Work Phone ____________________ Email _________________________________________ Parent/Guardian Home Phone _____________________ Cell Phone ______________________ Work Phone ____________________ Email _________________________________________ Local Newspaper _________________________________________________________________ Is this your first theatrical experience? If no, please list previous experience(s) ______________ ________________________________________________________________________________ Tuition Cost/Dates/Times Cost is $125 per student for two (2) weeks; or $105 per student for two (2) weeks if parent/guardian have two (2) or more students attending camp. A Waiver & Release and Permission & Registration form must be completed and signed for each student participating before student will be allowed to participate in Camp Hakuna Matata (if you have more than one student participating, you will need to complete and sign a form for each participating student). Tuition must be paid in full when submitting registration form. Payment methods accepted for Camp Hakuna Matata are check or money order (unless paying in person). Camp Hakuna Matata is 1:00-5:00, Mon-Fri, July 8-19. Camp Size Registration forms must be received by May 1, 2019. Camp size may be limited to keep it enjoyable and comfortable for all. Please mail/submit your registration early. Camp registration is not guaranteed until you receive a confirmation call and/or e-mail reply. (Calls/e-mails should not be expected until after May 20.) Age restrictions: Fifth-Twelfth Grade as of 2019/2020 school year. Refunds/Cancellation Cancellations before or prior to the first day of Camp Hakuna Matata will be reimbursed paid camp fee. Cancellations after the first day of Camp Hakuna Matata will not receive a refund or credit. Fees for camps cannot be transferred to other Southwest Playhouse Inc events. Size or nature of roles is at the professional discretion of instructor/director. All roles provide a valuable learning experience. No refunds will be granted due to dissatisfaction with assigned role. Registration Mail your registration form with payment (make checks payable to Southwest Playhouse) to: Southwest Playhouse, Attn: Camp Hakuna Matata, P.O. Box 204, Clinton, Oklahoma 73601. For any questions or concerns, please contact Melissa McSpadden at [email protected]. I, THE UNDERSIGNED, ACKNOWLEDGE THAT THE ABOVE INFORMATION IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND HEREBY GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN SOUTHWEST PLAYHOUSE’S CAMP HAKUNA MATATA. I FURTHER ASSUME RESPONSIBILITY AND POTENTIAL COST RESULTING FROM ANY INACCURATE INFORMATION. I CERTIFY THAT I HAVE FULL AUTHORITY TO SIGN THIS FORM WITH REGARDS TO THE ABOVE NAMED CHILD. Parent/Guardian (signature) ________________________________________ Date _____________ * Disney’s The Lion King JR Is presented through special arrangement with Music Theatre International (MTI). All authorized performance materials are also supplied by MTI. www.MTIShows.com. Music and Lyrics by ELTON JOHN & TIM RICE. Additional Music and Lyrics by LEBO M, MARK MANCINA, JAY RIFKIN, and HANS ZIMMER. Book by ROGER ALLERS & IRENE MECCHI. Based on the Broadway production directed by Julie Taymor. Music Adapted & Arranged and Additional Music & Lyrics and “Luau Hawaiian Treat” written by Will Van Dyke. “It’s a Small World” written by Richard M. Sherman and Robert B. Sherman. .

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