The Young People's Project

Registration

Fall 2019
Theatre Enrichment Workshops
for ages 12-16
Theatre Games & Life Skills
for ages 8 - 12


Student's Name
First :
Last:
Address:
City:
State:
Zip:
Phone #:
Emergency Phone #:
Student's Birth Date:
Current Age:
Gender: Female        Male

This registration is for:
YPP Theatre Enrichment Workshops
For ages 12 - 16
Mondays, Sept. 16 - Dec. 16
10am - 2pm
              select registration choice
$250.00
Theatre Games & Life Skills
For ages 8 - 12
Saturday, Sept. 21 - Oct. 26
10am - 11:30pm
              select registration choice
$90.00

Payment Information
Parents paying by check, please note, we must receive payment no later than four working days after submitting your registration. We do not reserve or hold spots in the workshops, and can not process your registration until payment is received. Please print out this form before submitting it, and mail in your check with a copy of your registration on the same day.

Families enrolling through the Inspire program, please print out this form before submitting it, and mail in your certificate with the registration copy.

Please check one of the following: I am paying by: :       Credit Card     Check   Inspire Certificate


PLEASE CHARGE MY ORDER TO MY:       VISA     MASTER CARD   DISCOVER
Total Amount Due $
Card Number: Expiration Date: CID#:
CID# is the three digit number located on the back of your credit card.
Name as it appears on the credit card:
Address associated with the billing address on the credit card:

Mail checks and Inspire certificates with a copy of your registration to::
PCPA
Attn: Education Outreach - YPP
800 S. College Drive,
Santa Maria, CA 93456-6399

Parental Permission Form

This form must be signed before a student can be enrolled in a Young People's Project program

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 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 programs 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 Intensives 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 workshops of my 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 any media, digitally or in print. 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.

I have read and agree to all as explained on this form and give parental permision to enroll my child listed above in the Young People's Project 2019-2020 Season.


Please check one:
Parent        Guardian

First Name*:

Last Name:

Parent or Guardian Email:


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


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