Belmont Academy Information and Release Forms


The Belmont is committed to providing individual attention to each child who participates. To ensure the good health, safety and attention needed, please complete and return this form to the Belmont administrative office. Children will not be permitted to participate without a signed and completed form. All information is confidential and will only be used to provide the individual attention each child needs and in case of emergency. Thank you for your cooperation.

Primary Contact Information

Emergency Contact Information (if we can’t reach you)

If a medical emergency occurs which involves the need to take your child to a doctor or hospital emergency room and we cannot reach you, we must have your written permission for us to seek medical attention or the doctor will not see your child. All efforts will be made to contact you or the emergency person listed above. Initialing below gives YLT permission to take your child to the nearest emergency room for treatment.

Sign-Out Release

In order to ensure the safety of all our Belmont children, we will not release a child to anyone other than a parent or legal guardian unless authorized to do so in writing. Please complete the portion of the form that applies to you. Thank you for your cooperation.

I give the following person(s) permission to pick up my child.

Photo/Video/Audio Release

The Belmont Theatre is dedicated to providing an educational and entertaining experience for all children and constant adult supervision is maintained for all activities. Please read carefully then sign and date the following statements:

By participating in this program, I:

  • Grant The Belmont Academy permission to take photographs and/or make video or audio recordings and use them in connection with the promotion or publicity for The Belmont Theatre.

  • Agree to indemnify and hold harmless The Belmont Theatre, its employees, agents, Officers, Board Members, Volunteers or any other person against loss or expense, including attorney fees, due to any bodily injury, personal injury or property damage which may result from any and all activities while participating in classes or any other activity sponsored by or conducted by The  Belmont Theatre, or while visiting any facilities owned by, leased by, or controlled by The Belmont Theatre.

I understand that every attempt will be made to contact me in the case of an emergency. In the event I can not be reached, I give my consent to emergency transportation, x-rays, medical treatment(s), surgery or dental care for my child as deemed necessary by the ER staff. I agree to assume responsibility for charges so incurred.

It is understood and agreed that this Release shall remain in force for not more than one year from the date below.

Camp T-Shirts: (Cost included in the Tuition)

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