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STUDENT LIABILITY WAIVER FORM
Students Name __________________________________________________________
Date of Birth _____________________________ Male __________ Female________
School ____________________________________________ Grade ______________
Parent(s)/Guardian(s) ( if under 18 )__________________________________________
Address ________________________________________________________________
City ___________________________ State _____________ Zip _________________
Phone (home) _________________________ (cell) ____________________________
Email (please print) ______________________________________________________
Emergency Contact ____________________________________ Phone ___________
Special Health Care Needs _________________________________________________
Special learning/Developmental Needs _______________________________________
Insurer & Policy # _______________________________________________________
*** READ CAREFULLY BEFORE SIGNING ***
RELEASE AND WAIVER: The undersigned understands that participation in Audience of One Educational programs at Capitol Theatre will expose students to activities and equipment which can cause accidents and injuries, and that Students will not be supervised outside of class time. The undersigned acknowledges receipt of the Conditions of Participation and agrees to abide by the requirements contained therein. In consideration of Students acceptance into AOO Educational Programs, that the undersigned does hereby release, waive, discharge, indemnify, and hold harmless Capitol Theatre, its directors, officers, employees and agents, from and against any claim for damage, injury, loss or death to the above named student resulting from participation in any class, program, play or other activity either at Capitol Theatre or at another location, including any damage, loss or injury resulting from failure to abide by the Conditions of Participation. With a childs registration in classes, parent/guardian grants permission to take pictures and recordings of class/performances for publicity and promotional purposes (website, publications, etc.).
HEALTH CARE AUTHORIZATION: The undersigned hereby authorizes Audience of One employees to do any acts which may be necessary or proper to provide emergency health care of any student in the event that the Parent/Guardian cannot be reached, including consent to and authorization of medical procedures by physicians, dentists, hospital or other emergency medical personnel, as they, in the exercise of their sole discretion, may deem necessary. The undersigned understands that (s) he is responsible for all costs and expense of such medical treatment.
I HAVE READ THE ABOVE WAIVER AND RELEASE LIABILITY AND BY SIGNING, I AGREE THAT IT IS MY EXPRESS INTENT TO EXEMPT AND RELIEVE AUDIENCE OF ONE PRODUCTIONS AND CAPITOL THEATRE AND ITS EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY OR WRONGFUL DEATH OTHER THAN CLAIMS THAT RISE AS THE DIRECT RESULT OF ACTIVE OR FORESEEABLE NEGLIGENCE. I CERTIFY THAT I HAVE FULL AUTHORITY TO SIGN THIS RELEASE AND AUTHORIZATION.
Student (if over 18) Parent/Guardian
__________________________________________ ___________________________________________
DATE ___________________________________
Audience of One will keep this form on file throughout a students enrollment in AOO Educational Programs
Please notify the staff of any changes to the above information. Thank you.
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