Student's Name:
City, State, Zip:
Phone #:
Emergency Phone #:
Birthdate & Age:
Gender: Female        Male
Last grade completed (K-12):
T-Shirt Size - Adult Small        Medium        Large        X-Large
T-Shirt Size - Child Small        Medium        Large        X-Large

This registration is for (check one):
Young People's Project (ages 13* - 18)
July 15 - July 22, 2017

*This student as completed the 7th grade.
YPP Jr. (ages 9* - 12)
July 23 - July 29, 2017

*This student has completed the 3rd grade.

Payment Information
Card Number: Expiration Date: CID#:
CID# is the three digit number located on the back of your credit card.
Names as it appears on the credit card
Associated with the billing address of the credit card

Should you wish to pay by check, fill out then print this form and mail it with a check to:
Attn: Education & Outreach YPP
800 S. College Drive,
Santa Maria, CA 93456-6399

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By submitting this form you agree to the following...
I am the parent or guardian of the student listed above and give my permission to participate in PCPA's Young People's Project, or YPP Jr. in association with Allan Hancock College and PCPA - Pacific Conservatory Theatre's Education & Outreach programming.

I agree to accept full responsibility for delivering the student to the class at the appointed hour and for picking up the student at the close of each session.

I agree to hold PCPA/Allan Hancock College or any officer, student, or employee thereof harmless from any claim for injury to the above named minor arising out of or in any way connected with Young People's Project and/or YPP Jr. in association with AHC Community Education of Santa Maria. PCPA, AHC, its officers, employees, or students will not be held responsible in any way for the health, safety, or welfare of the student while en route to or returning from any class or activity offered as part of PCPA's Young People's Project/YPP Jr. Community Education program.

I hereby authorize Marian Medical center as agent(s) for the undersigned, consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general and special supervision of any physician and surgeon licensed under the provisions of the medical staff when such diagnosis or treatment is rendered at said hospital.

The submission of this form also authorizes PCPA to publish photogaphs and/or video taken in YPP classes of your minor child named above and that there is no financial compensation of any type associated with the taking or publication of these photographs or video that may be used for company marketing materials and promotion of YPP on the Internet. I heareby release PCPA, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my child's participation.

Parental permision to enroll in the Young People's Projects

Parent or Guardian Name - First and Last*:

Parent or Guardian Email:

* I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.