SUMMER PATA REGISTRATION Each participant must be registered and paid for individually. General Registration Form Fill in missing information Performer’s Name * : Performer Information : First Name * : Last Name * : DOB (mm/dd/yyyy) * : Grade (entering this September) * : School * : Home Address * : Home Phone * : Cell Phone * : E-mail * : T-shirt Size * : SelectYouth SYouth MYouth LYouth XLAdult XSAdult SAdult MAdult LAdult XLAdult XXL Emergency Contact Information : Emergency Contact 1 * : Relationship to performer * : Phone Number * : Emergency Contact 2 : Relationship to performer : Phone Number : Medical Information : Primary Care Physician * : Phone Number * : Insurance Provider * : Group Number * : Policy Number * : Allergies/Dietary Restrictions (List N/A if not applicable) * : ÿ /s??n> Current Medications (Please include rescue inhaler, EpiPen, or other medication potentially needed during PATA.) (List N/A if not applicable) * : Medical Conditions (e.g., asthma, migraines, fainting) * : In case of emergency, do you give us permission to dispense over-the-counter medication to your child? If yes, indicate which of the following * : Yes No Ibuprofen Tylenol Tums Benadryl Zyrtec Hydrocortisone cream Or generic equivalent Does your child require any special accommodations? If yes, please explain. * Yes No Parent/Guardian Information Form Parent/Guardian 1 : Prefix * : First Name * : Last Name * : Relationship to performer * : Phone Number * : E-mail * : Parent/Guardian 2 : (optional) Prefix : First Name : Last Name : Relationship to performer : Phone Number : E-mail : Performer Pick-Up Information : Performers will only be released at the end of each day to parents/guardians or individuals specified below. Please provide the following information for others approved to pick up your child. *In case of changes to this list, please provide written permission. Name * : Relationship to performer * : Phone Number * : Name : Relationship to performer : Phone Number : Indicate any other pick-up or drop-off information (performer driving him/herself, etc.). Photo/Video Release I give permission to the PATAsphere to photograph and/or videotape my child/children and to use the images and any accompanying statements for all publicity purposes including but not limited to print ads, news releases, publications, TV, and PATAsphere social media pages (e.g. Facebook). My child’s images and/or statements may be used without liability for their use by the media, PATAsphere, and authorized employees. * Yes, I give my permission to photograph/videotape my child at PATAsphere. No, I do not give my permission to photograph/videotape my child at PATAsphere. Parent/Guardian Signature * : Release & Medical Consent : I agree to the above named person’s participation in Summer PATA, and waive, discharge and forever hold harmless PATAsphere, its officers, directors, employees and all other liabilities, claims, cause, damages or demands resulting from participation in usage of equipment or activities. In event of an emergency, I authorize that medical attention be administered to the participant named above. * By signing, I verify that I have read this form and the information provided is true and correct to the best of my knowledge. Parent/Guardian Signature * : Date * : Training Strand Selection The PATAsphere offers training in all aspects of performance - voice, dance, and acting. Please select one of the following training strands. Performers will receive more concentrated instruction in the primary area that they select. Note: Performers' primary area of training could be one that is already an area of strength for them, or could be an area that they would like to learn more about and receive more practice in during the summer program. Please select ONE of the following training strands: Dance (primary), voice (secondary), acting (tertiary) Dance (primary), acting (secondary), voice (tertiary) Voice (primary), dance (secondary), acting (tertiary) Voice (primary), acting (secondary), dance (tertiary) Acting (primary), voice (secondary), dance (tertiary) Acting (primary), dance (secondary), voice (tertiary) **Make sure all required fields are filled in.