"A Chance to Shine" Talent Submission

A Chance to Shine

Talent Showcase Focusing on Abilities, Not Disabilities

registration deadline 5/19

Any individual, duets, or groups with disabilities between the ages of 5-40 are invited to join us on stage to show off your talents! Singing, dancing, magic, stand-up comedy, impersonations, acting... we love the diverse abilities within our community, and we want to see YOU!

*Acts must not include crude content, strong language that could be deemed offensive, weapons, strobe lights, frightening content, confetti, silly string, or glitter. Acts must not be longer than 3 minutes. If a song is longer than 3 mins, we will work with you to cut it shorter. Individuals will need to provide their own costumes, props, etc. We will provide lighting and sound. If you have questions about permissable acts, please email Brooke at bhsieh@jacobschance.org.*

Participants may enter in multiple group acts, but participants interested in performing solo are limited to ONE solo entry. Please fill out this form ONCE for every act you wish to be a part of.

Show Date: Saturday, June 3rd

Show Time: 3pm (Arrival Time: 2pm)

Dress Rehearsal: Tuesday, May 23rd (5-8pm)

Location: Henrico Theatre (305 E Nine Mile Rd, Highland Springs, VA 23075)

Ages: 5-40

Entry Fee:

$10/solo act

$16/duet act

$25/group act

Jacob's Chance appreciates the continued support of Henrico Recreation and Parks, who is graciously sponsoring the venue! Another huge thanks goes to McGeorge Toyota for being our community level sponsor!

All proceeds from this fundraiser go to Jacob's Chance, 501(c)3, towards continuing to provide programs for individuals with disabilities in central VA.

To purchase tickets to attend the event as a guest, please click HERE!

PERFORMANCE REGISTRATION

$10 - Solo act

$16 - Duet act

$25 - Group act (3+ performers)

$15 - Additional Donation (optional)

Refund Policy

Jacob's Chance is able to process refunds up until a week prior to the start of the session, minus a 10% processing fee.

I acknowledge and accept the terms of the refund policy.

I CAN attend the dress rehearsal on Tuesday, May 23rd from 5-8pm.

Yes

Participant 1 Information

#1 Name

First Name

Last Name

#1 Age

#1 Email

Verify Email

#1 Participant's Diagnosis

#1 Any accommodations requested/helpful tidbits?

Is there anything we should know about the participant to ensure they have the most success possible?

#1 Are you willing to provide us with demographic information?

Data collection will be used only for grant compliance and internal review purposes.

Yes

#1 Race

Please check all that apply

Caucasian

Black or African-American

Asian

Indigenous American or Native Alaskan

Native Hawaiian or Pacific Islander

Hispanic or Latino

Not of Hispanic Origin

Other

Participant 2 Information

#2 Name

First Name

Last Name

#2 Age

#2 Email

Verify Email

#2 Participant's Diagnosis

#2 Any accommodations requested/helpful tidbits?

Is there anything we should know about the participant to ensure they have the most success possible?

Participant 3 Information

#3 Name

First Name

Last Name

#3 Age

#3 Email

Verify Email

#3 Participant's Diagnosis

#3 Any accommodations requested/helpful tidbits?

Is there anything we should know about the participant to ensure they have the most success possible?

Please list names & info for any additional participants:

Primary Parent/Guardian Contact

Contact Name

First Name

Last Name

Verify Email

Cell Phone Number

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Optional Additional Contact Information

Are there other adults that we should include in our communication about the event? Another parent, guardian, caregiver, etc?

Optional Additional Contact Name

First Name

Last Name

Optional Additional Contact Email

Verify Email

Optional Additional Contact Name

First Name

Last Name

Optional Additional Contact Email

Verify Email

Talent Information

Talent Category

Singing, dancing, instrument performance, magic, stand-up comedy, impersonations, acting, hula hooping, etc

Name of Each Individual Involved in Act

As it will appear in the event program!

Name of Song or Act

As it will appear in the event program!

Description of Act & Needs

Please describe in DETAIL what the act will look like. Please included needed equipment, props, lighting, music files, etc.

Time Length of Act

*Acts must be kept to a maximum of 3 minutes long.*

Media Waiver

Jacob’s Chance has my permission to use my or my child’s photograph publically to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I agree, on behalf of the participant, to the terms established by the above media waiver.

Yes

Health and Safety Waiver

In consideration of being allowed to participate in any way in the program, related events and activities, and use of equipment, I the undersigned, acknowledge, appreciate, and agree that:

The risk of injury from the activities involved in this program is significant, including the potential for paralysis and death.
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others and assume full responsibility for my participation.
I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Host, it’s officers, officials, agents, and/or employees, other participants, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to a person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
COVID-19 ACKNOWLEDGMENT AND WAIVER: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. While Jacob’s Chance is taking reasonable steps and precautions to lessen the risk of transmission of COVID-19 or other communicable diseases, and while Jacob’s Chance is following CDC guidelines and applicable state and county health department guidelines and orders, it is not possible to prevent against the presence of these diseases. THEREFORE, I RECOGNIZE AND UNDERSTAND THAT Jacob’s Chance is not responsible in any manner for any risks related to communicable diseases in connection with Participant’s participation in the activities. Specifically, I understand that COVID-19 is a highly contagious and dangerous disease and that contact with the virus that causes COVID-19 may result in loss, damage, expense or significant personal injury, sickness or death. I am fully aware that participation in the Activities carries with it certain inherent risks related to the transmission of communicable diseases that cannot be eliminated regardless of the care taken to avoid such risks, including, but not limited to: (1) the risk of coming into close contact with individuals or objects that may be carrying a communicable disease; (2) the risk of transmitting or contracting a communicable disease, directly or indirectly, to or from other individuals; and (3) injuries and complications ranging in severity from minor to catastrophic, including death, resulting directly or indirectly from communicable diseases or the treatment thereof (“Inherent Risks”). Further, I understand that all of the Inherent Risks are not fully understood and that the exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine. I hereby voluntarily accept and assume all risk of loss, personal injury, sickness, death, damage, and expense for myself arising from such Inherent Risks.

Furthermore, I represent and warrant that I do not knowingly carry any communicable diseases that may be transmitted during participation in the activities.

Health Statement

I will notify Jacob’s Chance ownership or employees if I suffer from any medical or a health condition that may cause injury to myself, others, or may require emergency care during my participation.

1365 Overbrook Rd, Richmond, VA 23220

804-640-8109

info@jacobschance.org

I agree, on behalf of the participant, to the terms established by the above health and safety waiver.

Yes

Name of individual responding to the above waivers:

First Name

Last Name