Child's Name ______________________________ Age ________ Grade in school (as of May 2006) ________

Your Name ________________________________ Relationship to Child ______________________________

Mailing Address ____________________________________________________ Zip Code _________________

Telephone: Home ________________ Work _________________ Cell ___________________

Email (mandatory- needs to be checked daily for important info) _____________________________________

In case of emergency, if we can't reach you, whom do we call?

Name ___________________________________ Phone ________________________

Child's Physician __________________________ Phone ________________________

Does your child have any physical problems, special medications, limitations of activity, or other considerations of which the staff should be aware? Please specify:





Has she/he had any previous performing experience? Any special skills (i.e., acting, singing, dancing, juggling, tumbling, etc.) Please specify briefly (use other side if necessary):





Can he/she play any musical instruments well?

Any times NOT available for rehearsal/performance between June 26 and Aug. 6? (Note: 1 or 2 missed rehearsals early in the schedule may be okay, however attendance at run-throughs, dress rehearsals and all performances is mandatory):



I, the undersigned, being a parent/guardian of the above, or being an active participant in Little People's Repertory Theatre, a program operated by the San Lorenzo Valley Youth Council, Inc., do hereby agree to hold harmless for injury, loss or damage the San Lorenzo Valley Youth Council, Inc. and any or all of its employees, and any or all individuals being paid or volunteering their services connected with San Lorenzo Valley Youth Council, Inc. programs. I also give employees of the San Lorenzo Valley Youth Council, Inc. the right to authorize emergency treatment and/or ambulance service for the above, if deemed necessary by the employee.


Signature of Parent or Guardian ________________________________________ Date: _________________


For Staff Use: Paid: ________