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* 1. Student Name

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* 2. Student Date of Birth

Date / Time

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* 3. I understand that I will be contacted by Pistarckle staff and given the next
steps and any additional paperwork needed to finalize and complete this
registration.

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* 4. I attest that all information included in Sections 1, 2 and 3 of this
registration are true and accurate to the best of my knowledge and that I am an authorized parent/legal guardian for this student and am able to make
decisions about his/her enrollment.

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* 5. I attest that this student does not have any physical, social - emotional or
cognitive impairments that would prohibit his/her safe participation or the
safe participation of others in the Playwright/Leadership program.

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* 6. I give consent for Pistarckle Theater to give my student  Ibuprofen or Tylenol upon their request during camp days within the limits prescribed on the
bottle

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* 7. In the event of an emergency, I give Pistarckle consent to have my student
attended to by EMT's or transported by Ambulance if I am not able to be
immediately contacted.

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* 8. I agree to fulfill any and all payment arrangements that I enter into for tuition or fees of $425.00 related to the Playwright/Leadership program, including the $25.00 non refundable registration fee.

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* 9. I consent to images of my student from camp, either in still or video, being
used in all promotional materials that Pistarckle may use during and after the PLaywright/Leadership camp.

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* 10. I understand that if my student is offered placement through Department of Labor or CDBG partnerships that I am responsible
for completing and/or providing all validating documents in the time frame
assigned at the time support is offered pending validation. I
understand that failure to follow such timeframes may result in the
placement opportunity being revoked. I understand that any offer of  supportassistance is only a pending offer until such time as documents are
submitted and validated. 

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