including everyone in the arts

2021-2022 Barrier-Free Adults sign up

Muncie Civic Theatre Barrier Free Adults - Formstack
Name*

In case of an emergency, please contact:

Emergency Contact Name*

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.)

Tuition.

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

Payment Method*
Do you need to apply for financial assistance to participate in the program?
(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 other individuals to create our own story and act in a play. 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 22, 2021 and run until April of 2022. I agree to be available to perform in the play on April 29th and 30th at Muncie Civic Theatre.

Informed Consent*

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*

COVID-19 WAIVER

Name
I have received the COVID-19 Coronavirus Vaccine*

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.

Use your mouse or finger to draw your signature above