BROADWAY WORKSHOP Application BROADWAY WORKSHOP "*" indicates required fields Δ InstagramThis field is for validation purposes and should be left unchanged.Participant's InformationPlease select which group you'd like to enroll in: Group 1 – 11:00am – 12:30pm Group 2 – 1:00pm – 2:30pm NAME* First Last NICKNAMEGRADE IN SCHOOL*Please enter a number from 3 to 7.AGE*Please enter a number from 9 to 12.DATE OF BIRTH* MM slash DD slash YYYY GENDER IDENTITY/PRONOUNSPlease list any medical conditions, chronic ailments, allergic reactions, disabilities or school IEP accommodations that we should be aware of:Parent/Guardian Contact InformationNAME (Parent/Guardian 1)* First Last RELATIONSHIP TO PARTICIPANT*ADDRESS (Parent/Guardian 1)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code MOBILE PHONE (Parent/Guardian 1)*WORK PHONE (Parent/Guardian 1)Is this person allowed to pick up/drop off the child? Yes* Yes No EMAIL (Parent/Guardian 1)* NAME (Parent/Guardian 2) First Last RELATIONSHIP TO CHILDADDRESS (Parent/Guardian 2) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code MOBILE PHONE (Parent/Guardian 2)WORK PHONE (Parent/Guardian 2)Is this person allowed to pick up/drop off the child? Yes No EMAIL (Parent/Guardian 2) Emergency InformationOther than parent/guardian, please list the next person you’d like us to contact in case of an emergency. EMERGENCY CONTACT* First Last RELATIONSHIP TO CHILD*EMERGENCY CONTACT MOBILE PHONE*Authorized PickupOther than parent/guardian, please list who else has permission to pickup your child.CONTACT INFORMATION Name Relationship to Child Phone Number CONTACT INFORMATION Name Relationship to Child Phone Number CONTACT INFORMATION Name Relationship to Child Phone Number CONTACT INFORMATION Name Relationship to Child Phone Number StatementPlease enter a statement describing any background the applicant has in theatre, music, or dance and /or their hobbies.*Please have the applicant write a statement explaining what they love about musical theatre and why they would like to be a part of the Broadway Workshop.*ScholarshipsA limited number of scholarships are available for the Broadway Workshop applicants.SCHOLARSHIPS I would like to apply for a Broadway Workshop Scholarship STATEMENT: Please provide a brief statement from a parent or guardian defining the financial circumstances of the Application request and why their child would benefit from the experience of attending Broadway Workshop.*ReleasesRelease of Liability* – I am aware that classes at Broadway Sacramento involve active activities, and I am voluntarily permitting my child to participate in these activities. I hereby agree to accept any and all risks of injury to my child/myself that may result therefrom. I agree that I will not make a claim against or sue Broadway Sacramento or any of its principals, employees, volunteers, or agents for injury or damage resulting from the use of the facility or other acts. I hereby acknowledge and agree to release indemnify and hold harmless Broadway Sacramento its principals employees and agents and to assume full responsibility for any loss or damage on account of injury to my child. Medical Release* – In case of an accident or an emergency, I hereby give my permission to the staff of Broadway Sacramento to authorize any emergency medical care that may be required during my child’s participation in classes and workshops. I authorize Broadway Sacramento to take my child to the nearest emergency hospital for emergency treatment and measures that are deemed necessary for the safety and protection of my child. I understand that Broadway Sacramento does not carry or maintain medical insurance coverage for any participant. I agree to take responsibility for full payment of any emergency medical costs related to my child’s participation regardless of whether I have insurance coverage. Broadway Sacramento staff can only administer limited first aid assistance (Band-Aids). Authorization to Reproduce Physical Likeness* – I expressly grant Broadway Sacramento and its employees and agents the right to photograph/ film/ or videotape my image and to use the resulting images in media promoting Broadway Sacramento and its activities. How did you hear about Broadway Workshop? Email from Broadway Sacramento Broadway Sacramento website Friend/Word of Mouth Social Media (Facebook, Instagram, etc.) Other This field is hidden when viewing the formBroadway Sacramento reserves the right to exercise discretion in accepting applicants. Enrollment is on a first-come, first-served basis and will end when we reach program capacity.
