Belmont Academy Information and Release Forms

EMERGENCY / HEALTH INFORMATION 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
Child's Name*	Last Grade Completed as of June 2017*
Parent/Legal Guardian Name*	Day Phone Number*
Email*
Emergency Contact Information (if we can’t reach you)
Name*	Relationship to Child*
Emergency Phone Number*	Alternate Phone Number*
Please list any physical injuries or chronic health problems of which we should be aware. (i.e. asthma, epilepsy, etc.)
Please list any medical restrictions, dietary restrictions, or allergies. (i.e. unable to climb stairs, vegetarian, allergic to bees, etc.)
Please list any special needs, conditions, or information of which we should be aware. (ADHD, vision or hearing impaired, etc.)
Is YLT authorized to provide simple first aid such as antiseptic ointment and band aid?* Yes No
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.
Physician’s Name*	Phone Number*
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 will be picking up my child at the end of each class/rehearsal. NOTE: If no, please complete information below.* Yes No
I give the following person(s) permission to pick up my child.
Pick Up Name 1	Pick Up Phone 1
Pick Up Name 2	Pick Up Phone 2
I am aware and agree that, once my child leaves The Belmont Theatre, The Belmont Theatre is no longer responsible for his/her whereabouts, actions or welfare.
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:
Your Child's Name*
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.
I hereby represent and certify that I am the parent or legal guardian of the child named above, and do hereby agree and give my consent and authorization without reservation to the foregoing on behalf of this person.
Camp T-Shirts: (Cost included in the Tuition)
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The Belmont Theatre Mission

The Belmont Theatre is York’s prominent community theatre, creating an environment of excellence in the theatre arts through diverse performances and innovative educational opportunities.

The Belmont Theatre
27 S. Belmont Street
York, PA 17403
Tickets: (717) 854-5715
Administrative Office: (717) 854-3894

Belmont Academy Information and Release Forms

EMERGENCY / HEALTH INFORMATION

Primary Contact Information

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

Sign-Out Release

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

Photo/Video/Audio Release

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

The Belmont Theatre Mission