Carlson 2015 Permission Form .pdf

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Elizabeth Anne Carlson Foundation for the Performing Arts
2015 Fall Musical Theatre Workshop - Permission Form
Student’s Name: ______________________________________________________________________________________
Address: ______________________________________City: ______________________ State: ______ Zip: __________
Student Phone Number: _______________________________________________________________________________
Parent/Guardian Name: ________________________________________________________________________________
Cell phone: (Mother) _____________________________________ (Father) ______________________________________
Parent’s Email: ________________________________________________________________________________________
Emergency Contact & Phone Number: ___________________________________________________________________
School: _______________________________________________________ Grade (Fall ‘15): _________ Age: __________

PUBLICITY/PROMOTIONAL ACTIVITIES
Portions of the Carlson Foundation workshop may be photographed and/or videotaped for promotional purposes
including but not limited to web site, brochure, photo CD’s newspaper ads/features or promotional/archival
videos. Does the Carlson Foundation have your permission to use your child’s image/name in promotional photos
(group or individual) or videos?
Yes______ No______
Parent/Guardian Signature: _______________________________________________ Date: __________________

ALLERGIES AND MEDICAL CONDITIONS
Please list any allergies or medical conditions that our staff should be made aware of:
____________________________________________________________________________________________________

PARTICIPATION PERMISSION SLIP AND RELEASE
I approve of my son/daughter _______________________________participating in the 2015 Fall Workshop
presented by the Carlson Foundation. As Student’s Parent or Guardian, I release the Carlson Foundation, and the
facility where workshop is being held, from any and all liability, damages, or claims whatsoever for any injury or
harm that may occur to my Student while participating in the workshop. I agree that I will make no claim or
demand against the Carlson Foundation, and the facility where workshop is being held, if an injury or accident
occurs during the workshop provided. I will look to my own resources, insurance, or assets to pay all medical bills,
damages or losses whatsoever if an injury occurs. The term Carlson Foundation includes all employees, volunteers,
and other staff participating in the 2015 Fall Musical Theatre Workshop. I also give permission to release my child
to my emergency contact listed above.
Parent or Guardian Signature: ______________________________________________ Date: ________________
Printed Name: ___________________________________________________________

Please complete and return this form NO LATER THAN Friday October, 9, 2015, to:
Audrey Carlson, 31 Franklin Circle, Newington, CT 06111, or via email: EACPerformingArts@gmail.com
Visit our web site at www.elizabethannecarlsonscholarship.com or call Audrey Carlson at (860) 841-5894 for more information.


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