*Student Last Name:
*Student First Name (Nickname):
*Pronouns:
*OBT School 2023-2024 Annual Session Level as stated on placement letter:
*Age as of September 5, 2023: *Birthdate:
*Gender: *Sex:
*Academic School (2023-24): *Academic Grade Level (2023-24):
Student Contact Information *If same as parent write N/A
*Address:
*City: *State: *Zip:
*Home Phone: *Cell Phone:
*Student's E-mail Address:
*(Please write N/A if student does not have a personal cell phone or e-mail address)
Parent/Guardian #1 Contact Information
*Relationship (mother, step-father, etc.):
Name (First and Last):
Address:
City: State: Zip:
*Home Phone: *Cell Phone:
*Home E-mail Address:
*Work Phone: Ext:
Parent/Guardian #2 Contact Information
*Relationship (mother, step-father, etc.):
*Name (First and Last):
*Address:
*City: *State: *Zip:
*Home Phone: () *Cell Phone: ()
*Home E-mail Address:
*Work Phone: () Ext:
*(Please write N/A if student does not have a second Parent/Guardian)
Person(s) to contact in an emergency if Parent/Guardian #1 and #2 are unavailable.
*Name (First and Last): *Relationship (grandmother, family friend, etc.)
*Phone:
*Name (First and Last): *Relationship (uncle, teacher, etc.):
*Phone:
Additional Information
If you would like to include additional child/family information, please send a note. Examples of helpful information might include custodial arrangements, restraining orders, family circumstances affecting attendance or tardiness, etc.
Lock Combination (Level 3 through OBT2 only):
(If students choose to use one of the OBT School lockers they must provide their own lock. OBT School/OBT does not accept responsibility for damage, loss, or theft of contents from any locker. Report any locker damage or loss of contents immediately to OBT School staff.)
Medical Release
This information is to help the OBT School/OBT, and their authorized agents seek medical attention for your student should you be unavailable in the event of an injury or emergency. We will make every effort to contact you, or a designated alternate, in the event of an emergency. This form provides our staff with the authorization necessary to treat or seek treatment for your student should an accident occur at the OBT School/OBT studios or performance venues. Furthermore, this authorization will be used in the event that emergency or hospital care becomes necessary.
Parent/Guardian Authorization:
The student herein described has permission to engage in all prescribed activities, except as noted by me, either individually or on the advice of a physician. The student’s history is correct and complete to the best of my knowledge.
I hereby grant permission to the OBT School's /OBT’s company physician and physical therapy staff (or in the event of emergency room care, the attending physician and/or ER staff) to order x-rays, routine tests, and/or treatment for the health of my student. In the event I cannot be reached in an emergency, I hereby grant permission to the physician selected by the OBT School/OBT to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my student, as named above.
*Medical Contact Information
*Student’s Physician:
*Physician's Phone: ()
Student’s Dentist/Orthodontist: Dentist/Orthodontist Phone: ()
*Medical Insurance Company:
*If student does not have medical insurance, write N/A.
Address: Phone: ()-
*Group #: Responsible Party:
Hospital of Choice**:
**This choice may not be accommodated due to the nature/severity of the injury or due to time restraints with respect to receiving immediate care.
Medical History
*List medications currently taken (If student does not take any medications, write N/A):
*List allergies (to medication, foods, etc.) (If student does not have any allergies, write N/A):
*Does the student have any medical condition, illness, or injury of which we should be aware, i.e., allergies, ADD/ADHD diagnosis, any orthopedic injury, chronic illness, medication use on site, etc. (If student does not have any medical conditions, illnesses, or injuries, write N/A):
Permission to Give Over-the-Counter Medication
Please check which of the following over the counter medications we may give your child without your additional permission?
Pediatric Motrin Pediatric Tylenol Pediatric Aspirin
Adult Ibuprofen Adult Tylenol Adult Aspirin
Child’s Weight (for dosage purposes only):pounds
Student's Initials: Date:
(Required Level 3 through OBT2)
Parent's/Guardian's Initials: Date:
(Required if student is under 18 years of age)
*Authorization to Pick-up & Permission to Leave Premises
*Person(s) who may pick-up student :
*Person(s) who may not pick-up student (If unsure, write All Others):
My child has permission to leave OBT School/OBT’s studios, unchaperoned, for breaks:
Yes No
My child has permission to leave OBT School/OBT’s studios, unescorted, after class:
Yes (complete information below) No (suggested option for students under 12)
Will the student be in possession of a cell phone?
No Yes Student’s cell phone number: ()-
Will the student use public transportation after class?
No Yes Bus/Route Number Bus Stop ID/Location
Will the student walk home after class:
No Yes Direction walking from OBT School/OBT
Parents may update this form at any time. Please notify the school in writing if there are any permanent or temporary changes to the above information.
Student's Initials: Date:
(Required Level 3 through OBT2)
Parent's/Guardian's Initials: Date:
(Required if student is under 18 years of age)
Production Release and Commitment
(For Levels 1 through OBT2)
In consideration of the opportunity to participate in the auditions, rehearsals, promotions, and performances of Oregon Ballet Theatre (OBT) and OBT School, I individually and/or as a parent or guardian on behalf of a minor, on behalf of myself, my heirs, executors, administrators, and assigns, agree to defend, hold harmless, indemnify, release, and forever discharge OBT/OBT School, its employees, members, agents, officers, trustees, or affiliates for any and all claims, demands, actions, or causes of action on account of any damage to any real or personal property or any accident, illness, personal injury, or other consequences that may arise or result from my/my child’s participation in any and all activities related to productions in the above noted time frame.
I attest and verify that I have full knowledge of the risks involved in this production, that I freely and voluntarily assume, authorize, and pay for my own/my child’s medical and emergency expenses in the event of accident, illness, or other incapacity. I authorize OBT/OBT School and its agents to obtain emergency medical treatment for my child as they may deem necessary or appropriate if I am not readily available to do so, and agree that OBT/OBT School and its trustees, officers, employees, agents, insurers, successors, and assigns shall not have any liability for taking such action. I state that I am/my child is physically fit and sufficiently trained to participate in OBT/OBT School productions.
I hereby grant full permission to OBT/OBT School and any and all sponsors involved in OBT/OBT School productions to use for publicity or promotional purposes my own/my child’s name and/or picture of me/my child participating in OBT/OBT School productions without obligation or liability to me.
I agree that I am/my child is a volunteer who is donating my/his or her services to OBT/OBT School for no compensation, without expectation or contemplation of compensation as the adequate consideration for services performed for this non-profit corporation.
Notice of Commitment
If you are chosen to be part of an OBT/OBT School production, you must be aware of the major commitment this will require of both you and your parent/guardian. Each child cast for a role is required to attend every rehearsal and performance as required by their role.
By initialing below I have read and agree to the above Production Release and Commitment conditions:
Student Initials: Date:
Parent/Guardian Initials: Date:
(required only if student(s) is(are) under 18 years of age)
Disclosure
(Required for all students)
Please read carefully through the following disclosures. Your signature verifies your agreement to the terms required of all registered students. In signing this registration form, I, the student, and we, the parent(s)/guardian(s), acknowledge our commitment, including financial, to fulfill the entirety of our registered session. Oregon Ballet Theatre School reserves the right to terminate a student’s enrollment if they are unable to participate in accord with OBT School’s expectations of timely payment of tuition, attendance, or conduct.
OBT School refunds 100 percent of tuition fees for classes, workshops, masterclasses, and other fee-based instruction, canceled due to low enrollment. In the event of circumstances beyond its reasonable control, including acts of God, earthquakes, fires, floods, inclement weather, civil disturbances, epidemics, and riots OBT School will do its best, if possible, to offer make up class options. Make up class schedules are at the sole discretion of OBT School and may not accommodate each student’s specific scheduling requirements. In the event OBT is not able to offer make up classes, the organization will consider all refund requests, though approval of a refund shall be at the discretion of OBT. Refunds exclude, but do not solely exclude, registration, finance, NSF, audition fees, and first tuition or housing payments within installment tuition contracts.
OBT School and OBT shall have the absolute sole and perpetual right and permission to use, publish and/or reproduce in any form or any manner, photograph, film, videotape, audiotape, digital recording, or any other form of representations in which the publicity during the term of this Agreement shall be under OBT School’s/OBT’s sole control, and the student shall cooperate by engaging in such publicity and activities as may be directed by OBT School/OBT. The student shall not communicate with the media except under coordination with and approval of OBT School/OBT.
It is agreed that I, my child, adopted or otherwise, and my heir and executors, waive and release all rights and claims for damages that I may have at any time against OBT School/OBT, its representatives whether paid or volunteer, for any injury or damages in connection with OBT School's curriculum or other activities related to OBT School/OBT, including
but not limited to OBT's studios, rehearsal and performance spaces, and virtual learning programs related to OBT School/OBT. The risks involved with respect to such a program are fully understood. I authorize OBT School/OBT and its employees or agents to provide or secure emergency medical treatment for me or my child on my behalf if deemed necessary.
I have read, understood, and agree to all the terms that are set forth as requirements on this registration form. I realize that it is my responsibility to familiarize myself with OBT School’s policies and expectations, through the printed and published materials made available to me. This release is valid for the registered session listed on this form.
Student Initials: Date:
Parent/Guardian Initials: Date:
(required only if student(s) is(are) under 18 years of age)