Registration | Conservatory

Summer 2017 Conservatory and Registration

Come join the cast and crew for our five week Summer Theatre Conservatory as we proudly present Gilbert & Sullivan's The Pirates of Penzance.
Pirates of Penzance is a rollicking opera featuring gentlemen pirates, a bevy of beautiful girls, and the hilarious Modern Major General who sings the fastest rhymes in musical theatre history. Green Room Theatre's production will be costumed in glorious steampunk fashion with the girls in Japanese babydoll Harajuku dresses. If you have watched the movie version, our production will be entirely different: bigger, faster, and funnier.

June 19 - July 20, 2017

Scholarships available
Classes divided by age;
- Actors 18-24
- Actors 13-17
- Actors 8-12
- Technical internships and technical crew
All skill levels welcome
Training is available at advanced, intermediate and introductory levels
Learn theory, acting, voice, dance, stagecraft and more.
Classes held at CSUSB, Palm Desert Campus*
Performances at the Indian Wells Theater on July 19 and July 20, 2017

Tuition: $495
*not affiliated with CSUSB

Register here:

* Indicates required field

Student Name *

First

Last

Age *

Name of Parent/Guardian 1 (if student is a minor) *

First

Last

Address *

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Line 2

City

State

Zip Code

Country

Name of Parent/Guardian 2 (if student is a minor) *

First

Last

Address 2 *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Email 2 *

Cell Phone *

Cell Phone 2 *

Work Phone *

Work Phone 2 *

School Attending (if applicable) *

Home Phone *

Home Phone 2 *

About the Student

Grade (if applicable) *

Experience on stage. *

This is not a prerequisite; we just want to know more about your child. Include music, singing, dancing, etc.

Anything interesting you would like us to know about the student? *

List awards, hobbies, interest, quirks, or anything you’d like to mention.

Any health problems, disabilities, or learning disabilities? Section (504) *

Does the student have an Individualized Education Plan (IEP)? *

If you answered yes to the Individualized Education Plan (IEP), please explain. *

How did you hear about us? *

Does your child take any medications? *

If yes, please list all medications. *

Any allergies to food or other substances? *

Emergency Contact 1 *

First

Last

Phone Number *

Emergency Contact Other Than Parent(s)
If student is a minor: My son/daughter may be released to the following:

Emergency Contact 3 *

First

Last

Phone Number *

Emergency Contact 2 *

First

Last

Phone Number *

Insurance Information

Insurance Carrier *

Group Number *

ID Number *

Authorization of Consent

(I), (We) the undersigned, do hereby authorize an instructor of Green Room Theatre Academy as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable.

This authorization shall remain effective through December 11, 2017.

Comments or Special Instructions *

Pickup and Drop Off Procedure

I have read and agree with drop off and pickup procedures in the manual. I understand that Green Room Theatre Academy will only release underaged students to the student's parents/guardians or anyone else listed below.

Acknowledgement of Pickup and Drop Off Procedure *

Yes, I have read and consent to the pick up and drop off procedure. No, I do not agree.

If not, please provide contact information for both parents, unless child is under sole custody. Please include any other legal guardians. *

We ask that you refrain from flash photography and videotaping during the show as the cameras are distracting to actors and audience. Please save photo session for after the show. Green Room Theatre never admits children age 4 and under, who might fudget or fuss, to our conservatory performances.

If student is a minor, do parents live together? *

Agreement to Polices and Procedures Manual

I have read and agree to abide with all procedures and policies manual.

Authorization of Consent for Treatment of a Minor Student: *

Yes, I Consent. No, I Do Not Consent.

Authorization of Consent for Treatment of an Adult Student: *

Yes, I Consent. No, I Do Not Consent

Select One *

Yes, I agree with all procedures and policies. No, I do not agree with all procedures and policies.

Parent Volunteering and Involvement

We love parent volunteers! Volunteers help get our shows done and keep tuition costs down. We encourage you to be involved and join the fun.

Please mark the sections of any areas you would like to help out. *

I Have a Pickup or Van to Use I can help transport smaller items in my car before 12:00 Administrative Development Graphic Arts Marketing Publicity Social Media Special Events Backstage Supervision During Shows Carpentry Catering & Concessions Clean Up & Strike Lighting, Sound, Electrics Makeup Photo Documentation Scenic Art Set Up Day of Show/Breakdown Sewing/Costumes Videography

Do you have a special show business experience, special talent, or have a special connection that you would like us to know about? *

Hold Harmless Agreement

The undersigned agrees to indemnify, and hold harmless Green Room Theatre Company, and all its assigns, employees, agents, individually and collectively from and against all costs, losses, claims, demands, suits, actions, payments, and judgments, including legal and attorney fees, arising from any and all personal or bodily injuries, property damage, or otherwise, however caused, brought or recovered against any of the above that may arise for any reason from this class.

In case of emergency, I give the person in charge of Green Room Theatre Academy my permission to administer first aid or to obtain medical treatment for the child in emergencies. I agree to hold Cal State San Bernardino, any employee or volunteer of Cal State San Bernardino free from any liability if any problems, complications, or injuries arise from such treatment. GRTC’s staff is authorized to use its best judgment to select appropriate medical treatment from physicians and hospitals designated by the parents.

Any doctor or hospital to which the child is taken to is hereby authorized to render any and all necessary emergency treatment. We will make all efforts to contact the parent first. The parents of the child named below agree to assume full responsibility for any expenses incurred with this emergency treatment.

Hold Harmless Consent *

Yes, I Consent. No, I DO NOT Consent.

Physician Name *

First

Last

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Physician Phone Number *

Hospital or Clinic *

Insurance Provider *

ID Number *

Group Number *

This agreement shall be construed to require Green Room Theatre Company and its staff to exercise usual and customary care for child named above.

Consent to Care *

Yes, I Consent. No, I Do Not Consent.

Submit

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Summer 2017 Conservatory and Registration

Register here:

About the Student

Insurance Information

​Authorization of Consent

Pickup and Drop Off Procedure

Agreement to Polices and Procedures Manual

Parent Volunteering and Involvement

Hold Harmless Agreement

Authorization of Consent