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Arts Alive Musical Theatre Registration
Arts Alive 2018
Step 1 of 5
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Grade level for 2018/2019 academic year
My child would require transportation via bus
Parent/Guardian will drive student
Student will drive themselves
Student will bike or walk
If taking advantage of provided transportation, choose a pick-up location
Carbondale Area High School
Burlington Coat Factory, Eynon
Gerrity's Supermarket, Clarks Summit
Western Wayne High School
I grant permission for my child to be transported to and from the Arts Alive program
I have requested transportation to and from the Arts Alive program for my child, and hereby grant permission as a parent or legal guardian, to the agents of NEIU to transport my child to and from the program on a daily basis.
Does your child have a medical condition that may affect his/her participation in Arts Alive?
Does your child have any allergies?
Does your child have any limitations that would prevent him/her from participating in physical activity?
Name of child's hospitalization insurance company:
Policy or Medicaid Number:
Policy is under the name of:
I give permission for my child to receive treatment in the event of an emergency.
In the event that my child becomes injured or ill during the Arts Alive program, I authorize the transportation of my child to a hospital for treatment. If, in the judgments of Arts Alive staff, the illness or injury is sufficiently serious, I understand that a staff member will contact me at the telephone number given below if such treatment is deemed necessary. I understand that I am responsible for ambulance or hospital charges.
Primary Emergency Contact
Primary Emergency Phone
Secondary Emergency Contact
Secondary Emergency Phone
Photo and Video Release
I agree to photo and video release
I do NOT agree to photo and video release
In consideration of my son/daughter's engagement as a photo or video subject by the Northeastern Educational Intermediate Unit (NEIU) and the Arts Alive program, I hereby grant the right and permission to copyright, use, reuse and publish photographs or videotape images made of my son/daughter for the Arts Alive program's educational purposes, including use in advertisements for public relations and development purposes. I hereby release NEIU and its authorized representatives, including the photographer or videographer, from any liability by virtue of any blurring, distortion or alteration that may have occurred in the making of such images and from any liability for claims of libel or invasion of privacy for any reason.
Hold Harmless Agreement
I have read and understand the Hold Harmless Agreement
As parent/guardian of a participant in the NEIU sponsored Arts Alive program, I understand that NEIU does not provide any medical insurance coverage for the accidental injuries or illness or coverage for accidental injuries or illness or coverage for personal property damage. I agree to release and hold harmless, NEIU and the Arts Alive program from any and all responsibility for any injuries or damages not directly caused by negligence of the program its officers, agents, or employees.
I have read and understand the regulations.
My child agrees to abide by all programs and regulations while attending the Arts Alive program. We understand that the possession or use of alcoholic beverages, unauthorized drugs or a weapon of any kind is grounds for immediate expulsion from the program. We also understand that disruptive behavior will result in immediate dismissal. Refunds are not granted if my child is dismissed from the program.
Lost or Stolen Articles
I have read and understand Lost and Stolen Articles
I understand that NEIU, The Everhart Museum, Ballet Theatre of Scranton, and Goodwill Industries are not responsible for any lost or stolen articles.
I give my permission for my son/daughter to attend the Arts Alive program. I understand that during the course of the program the students will be in various locations for periods of time, but fully supervised as they participate in the program. I understand that daily attendance is mandatory and that the only excusable absence would be for medical reasons.
Full payment MUST be received no later than JULY 1, 2018 in order to be eligible to participate in the program.