New England Youth Theatre · Health & Release Form 2024

Student Information

Student Information Copy

Student's Name

*

First Name

Last Name

Goes by:

*

Program

*

Date of Birth

*

(mm/dd/yyyy)

My child's personal pronouns are:

*

she/her

he/him

they/them

other

Other:

Student Email

Verify Email

Student Phone

Parent/Guardian Contact Information

PARENT/GUARDIAN #1 NAME

*

First Name

Last Name

Relationship to Student

*

Mailing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Primary Phone

*

Additional Phone

Email

*

We will use this email address to confirm receipt of this form.

Verify Email

*

PARENT/GUARDIAN #2 NAME

First Name

Last Name

Relationship to Student

Phone

Email

Verify Email

Emergency Contact Information

EMERGENCY CONTACT NAME

*

First Name

Last Name

Relationship to Student

*

Phone

*

STUDENT'S PHYSICIAN + PHONE

*

Medical Information

Please note all medical conditions we should be aware of, such as: asthma, seizure disorder, allergies to food or bee stings. If you would like a staff member to administer an injection in case of bee sting, be certain to provide written permission, instructions and a supply of unexpired medication. All medical information is confidential and is crucial to have on file in case of medical emergency. NEYT’s emergency protocol is to contact parents and/or Rescue, Inc., and, if necessary, permit treatment at Brattleboro Memorial Hospital. If you would like to arrange a different procedure, please contact our office directly.

Medical Conditions

Related Medication(s)

Medical Authorizations

I give permission for the student listed above to participate in NEYT programs.

*

By selected YES below, I understand the potential risks associated with these programs, including but not limited to: falls, contact with other participants, weather, traffic, and other reasonable risk conditions. I consent to release NEYT from all liability on behalf of the participant.

Yes

No

In the event of an emergency requiring medical treatment, I give my permission for the student listed above to be treated at Brattleboro Memorial Hospital.

*

Yes

No

Emergency Medical Treatment

*

I authorize NEYT personnel to provide emergency medical treatment for the student listed above in case of injury or illness, including treatment advised by qualified medical professionals. This authorization is granted only if I cannot be reached (and a reasonable effort has been made to do so) or under life threatening circumstances.

Yes

No

Social, Emotional, & Cognitive Differences

NEYT is committed to providing an inclusive theater experience for all of its students. Social, emotional, and cognitive differences do not mean negative consequences for casting; in fact, some of our most successful students identify as ‘different’ from the norm in one way or another. The more we know about the individual differences of your child, the more we can support your child’s success. All information given is strictly confidential.

My child benefits from extra help with reading:

My child might need help with transitions between activities:

My child might need help redirecting their attention to the task at hand:

My child thrives on a lot of physical activity:

My child might need extra emotional support:

My child learns best when spoken instruction is accompanied by visual aids:

My child might need help making friends:

Is there any helpful guidance you can give us to make the best possible experience for your child?

Permissions

Photo/Video Release:

*

I give my permission for NEYT to use photos or video clips of my child in any press, poster, NEYT website, NEYT social media, or other promotional materials developed to support this production/class/camp or other NEYT promotional purpose.

Leaving Campus:

*

My child has permission to leave campus for lunch and rehearsal breaks when applicable.

PARENT/CAREGIVER SIGNATURE

*

By typing your name, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.