Barrier-Free Sign Up - Muncie Civic Theatre

Name*

First Name

Last Name

Email*

Primary Phone Number*

Date of Birth*

Age

In case of an emergency, please contact:

Emergency Contact Name*

First Name

Last Name

Emergency Contact Email*

Emergency Contact Phone Number*

Please list any important information you feel is important for Tracena to know about you while participating in the program (ie: any food allergies, use of mobility or communication device, sensitivities to sounds, etc.)

Health Information

Tuition.

The value is $200 for the program. This rate breaks down to $25 per month (8 months).

Payment Method*

I prefer to pay $25 monthly through April 2022 I will pay the full payment of $200 via Credit Card now I will pay via check at the start of the program in September

Do you need to apply for financial assistance to participate in the program?

No, I do not need to apply for financial assistance. Yes, I will need to apply for financial assistance.

(financial assistance is not guaranteed - it is offered based on the amount of funding received for the program each year and is given on a first-come, first-serve basis. It may cover up to 50%-100% of the program cost)

I hereby consent to participate in the Barrier-Free Theatre program. I understand that Tracena Marie will be working with myself and others to create our own story and play to perform at Muncie Civic Theatre. I understand that by signing this form, it is important for me to attend the Wednesday rehearsals from 3:45-5:45. Rehearsals will begin on September 14, 2022 through April 8, 2023. I agree to be available to perform in the performances on April 7th and 8th (both shows start at 7:00 p.m.) at Muncie Civic Theatre.

Program Start Date: Wednesday, September 14th

Time: 3:45-5:45 p.m.

Frequency: Meet weekly on Wednesdays (with no rehearsals during Ball State University's academic breaks)

Performances: April 7th and 8th at 7:00 p.m.

Informed Consent*

Yes, I can commit to the program. No, I cannot commit to the program.

I hereby consent to be photographed or recorded while participating in the Barrier-Free Theatre program. The photos/videos may be used by Muncie Civic Theatre and Tracena Marie for educational research, conferences, promotional, and grant writing purposes.

Media Release*

Yes, I give permission. No, I do not give permission.

COVID-19 WAIVER

Name

First Name

Last Name

I have received the COVID-19 Coronavirus Vaccine*

Yes No Prefer not to answer

Other:

By participating in this production as a volunteer actor 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

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Use your mouse or finger to draw your signature above

including everyone in the arts

2022-2023 Barrier-Free Adults sign up

In case of an emergency, please contact:

Tuition.

COVID-19 WAIVER