Broadway At Music Circus – TEENS Application Broadway At Music Circus TEENS Application "*" indicates required fields Participant's InformationNAME* First Last NICKNAMEGRADE IN SCHOOL*Please enter a number from 8 to 12.AGE*Please enter a number from 13 to 18.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:BROADWAY AT MUSIC CIRCUS TEENS T-SHIRT SIZE*Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargeUnisex SmallUnisex MediumUnisex LargeUnisex X-LargeParent/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 participant?* Yes No EMAIL (Parent/Guardian 1)* NAME (Parent/Guardian 2) First Last RELATIONSHIP TO PARTICIPANTADDRESS (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 participant? 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 PARTICIPANT*EMERGENCY CONTACT MOBILE PHONE*Authorized PickupOther than parent/guardian, please list who else has permission to pickup your participant.Will the participant be driving themselves?* Yes No 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 Broadway At Music Circus Teens.*ScholarshipsA limited number of scholarships are available for Broadway At Music Circus – TEENS applicants. Please indicate below whether you are interested in applying by April 1, 2024.SCHOLARSHIPS I would like to apply for a Broadway At Music Circus – TEENS Scholarship STATEMENT: Please provide a brief statement from a parent or guardian defining the circumstances of the Application request and why their child would benefit from the experience of attending Broadway At Music Circus – TEENS.*ReleasesRelease of Liability* – My child has permission to attend Broadway At Music Circus – TEENS (June 18 to August 3, 2024). I understand that I am releasing Broadway Sacramento and the Broadway At Music Circus – TEENS instructors and volunteers from any and all liabilities incurred while at the program. Authorization to Reproduce Physical Likeness* – I expressly grant to Broadway Sacramento and to its employees and agents the right to photograph, film, or videotape my child and to use the resulting images in media promoting Broadway Sacramento and its activities. I further grant the right to record and reproduce my child’s voice and all instrumental, musical, and other sound effects produced by my child. I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof. How did you hear about Broadway At Music Circus – TEENS? 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.CAPTCHAPost BodyEmailThis field is for validation purposes and should be left unchanged.
