Registration | Conservatory

Fall 2017 Conservatory and Registration

Green Room Theatre Company is offering a creative dramatics class for young actors ages 5-7.

Students will be able to:

Use their imagination to make creative acting choices
Learn creative acting habits
Collaborate with other actors in a safe environment
Practice public speaking and stage presentation
Perform learned skills in front of invited public audience

Instructor: Christine I'Anson
Location:
Create Center for the Arts
73-446 Highway 111
Palm Desert, California, CA 92260

Times and Dates between 4 PM and 5 PM as follows:
October 16
October 23
October 30
November 6
November 13
November 20
November 27

PERFORMANCES (Times TBA):
December 2
December 3
December 4
with more hours during performance week.

Training is intensive and students and parents should be prepared to commit to every day of the Conservatory.

Tuition: $150

Register here:

* Indicates required field

Student Name *

First

Last

Age *

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

First

Last

Address *

Line 1

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 *

Experience on stage. *

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

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

Emergency Contact 1 *

First

Last

Phone Number *

Emergency Contact 2 *

First

Last

Phone Number *

Emergency Contact 3 *

First

Last

Phone Number *

Insurance Information

Insurance Carrier *

Group Number *

ID Number *

Hospital or Clinic *

Physician Name *

First

Last

Physician Phone 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 20, 2017.

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

If not, please provide contact information for other parent or other legal guardians. *

Agreement to Polices and Procedures

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

Authorization of Consent for Treatment of a Minor Student: *

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

Authorization of agreement with policies and procedures: *

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.

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 Company my permission to administer first aid or to obtain medical treatment for the child in emergencies. I agree to hold Green Room Theatre Company, any employee or volunteer of Green Room Theatre Company and Create Center for the Arts 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.

Submit

Fall 2017 Conservatory and Registration

Register here:

About the Student

Insurance Information

​Authorization of Consent

Agreement to Polices and Procedures

Parent Volunteering and Involvement

Hold Harmless Agreement

Authorization of Consent