Youth Registration Form - Muncie Civic Theatre

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Muncie Civic Youth Registration Form - Formstack

Muncie Civic Youth Education Theatre Registration

Please fill out all the fields below completely. After registration, you will be sent an email with more information about scholarships and payment.

Student Name (Please use your child’s preferred name. This is the name we will use on nametags, programs, and other publications)*

First Name

Last Name

Student Gender: *

(This information helps us prepare materials for auditions.)

Student Grade Level - for 2021-2022 School Year*

Program Student is registering for*

Student Picture No File Chosen

File uploads may not work on some mobile devices.

Please upload a recent headshot of your child

T-Shirt Size*

Guardians' Names*

First & Last Name

Guardian Email*

This email will be used for all Civic communication, please make sure it is one you check often

Student Email (if applicable)

Additional Guardian Email - If desired

This email will be used for all Civic communication, please make sure it is one you check often

Guardian Contact Phone Number*

Additional Guardian Contact Phone Number

Emergency Contact Number*

Students may receive approval for absences up to 2 rehearsals. Looking back at the website for rehearsal and performance dates and times, what conflicts do you have?*

Medical Information

List any Medical Conditions or Potential Dangers we should be aware of (include allergies and medicine needed here.)*

Inclusion Information

List any other items our team should be aware of to ensure your child's success in our program (include learning disabilities, triggers, etc. here.)*

Media Release Statement

As a non-profit community theatre, we rely on social media and other marketing materials to share the great things our program is doing in the community. Please let the education director know if you want your child to opt out of any marketing materials social media.*

I have read the media release statement.

Demographic - Information

Muncie Civic Theatre's Youth Education program is significantly funded through grants. Consider providing your information here, so that the theatre may provide accurate information to those providing funds. This information will be used solely for grant writing purposes and will not be shared with our theatre volunteers.

School Attending

County of Residence

Race

Annual Household Income

COVID-19 WAIVER

The participant has received the COVID-19 Coronavirus Vaccine*

Yes No Prefer not to answer

Other:

By participating in this production during a time of a declared national health emergency, I fully understand the risks of possible exposure to the novel Coronavirus known as COVID-19. In full knowledge of this possibility and the potential severity of symptoms and effects of this disease, including but not limited to the possibility of death or lifelong health consequences, loss of work or freedom of movement due to quarantine, I am electing to participate in the above selected production and assuming these risks. Having voluntarily assumed this risk, I hereby waive my rights to any and all claims I may have now or in the future against Muncie Civic Theatre, its Board, employees, and agents related to exposure to COVID-19.

Full Legal Name:

Signature or Parent's Signature if under 18

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The Muncie Civic Theatre mission is to enrich our whole community through theatre performance, education, and outreach.

765.288.PLAY

216 E. MAIN STREET

MUNCIE, IN 47305

BOX OFFICE HOURS

TUES-FRI 12-6 PM

The Muncie Civic Theatre mission is to enrich our whole community through theatre performance, education, and outreach.