CECILY TYSON WORKSHOP REGISTRATION FORM
Beginner's Class
11:00 AM- 1:00 PM
Saturdays, January 18 to March 22, 2025
Suggested Donation of $5 per class
  • EMERGENCY INFORMATION


    Emergency Contact's Name:


    Relationship:


    Mobile Number:




    Informed Consent and Acknowledgement: I approve my child’s participation in
    the activities of The Cicely Tyson Theatre Workshop at St. Philips Episcopal
    Church during the selected class period. In exchange for accepting my child’s
    participation, I assume all risks and hazards incidental to the conduct of its
    activities and release, absolve, and hold harmless all its respective instructors
    and representatives from any liability for injuries to my child arising out of
    dramatic improvisation, creative exploration, or traveling to, participating in, or
    returning from selected field trips. (We will always provide class supervision and
    chaperones for field trips.)

    Medical Release and Authorization
    As Parent or Guardian of the named student, I hereby authorize the diagnosis
    and treatment by a qualified and licensed medical professional of the minor child
    in the event of a medical emergency, which, in the opinion of the attending
    medical professional, requires immediate attention.

    Confirmation: I ACKNOWLEDGE AND AGREE TO THE ABOVE BY SIGNING
    BELOW



    Parent/Guardian Signature:
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