Lakewood Center for the Arts

THEATRE & ART CLASS REGISTRATION FORM
Lakewood Center for the Arts
Lake Oswego, Oregon

MAKE CHECKS PAYABLE TO LAKEWOOD THEATRE COMPANY

Class: ___________________________________

Student's Name:____________________________

Age:___________________

Address:__________________________________

City, State, Zip:_____________________________

Home Phone:______________________________

Work Phone:_______________________

Tuition: $__________________________________

School Grade
(for registrants under 18)_______________

Medical Consent And Release From Liability And Indemnifications:
I, (as signed on the registration form) for myself and/or as parent/guardian of the named registered child, do hereby authorize employees of the Lakewood Theatre Company/Lakewood Center to consent to emergency medical or dental examination, treatments, etc., to be administered to the same in the event of accident or sudden illness during LTC/Lakewood Center programs. In addition, I agree that I am responsible for the said participants' transportation to and from the class or activity site. I hereby release and discharge the LTC/Lakewood Center, its officers, agents, and employees from any and all claims for personal injuries. I also agree that pictures taken during program hours may be used for future promotional purposes. The LTC/Lakewood Center does not provide any medical insurance for any participant in any program.

Signature_________________________________

Date_____________________

Make checks payable to LTC, PO Box 274, Lake Oswego, OR 97034

THEATRE & ART CLASS REGISTRATION FORM Lakewood Center for the Arts Lake Oswego, Oregon
	MAKE CHECKS PAYABLE TO LAKEWOOD THEATRE COMPANY

Class: ___________________________________
Student's Name:____________________________	Age:___________________
Address:__________________________________
City, State, Zip:_____________________________
Home Phone:______________________________	Work Phone:_______________________
Tuition: $__________________________________	School Grade (for registrants under 18)_______________


Medical Consent And Release From Liability And Indemnifications: I, (as signed on the registration form) for myself and/or as parent/guardian of the named registered child, do hereby authorize employees of the Lakewood Theatre Company/Lakewood Center to consent to emergency medical or dental examination, treatments, etc., to be administered to the same in the event of accident or sudden illness during LTC/Lakewood Center programs. In addition, I agree that I am responsible for the said participants' transportation to and from the class or activity site. I hereby release and discharge the LTC/Lakewood Center, its officers, agents, and employees from any and all claims for personal injuries. I also agree that pictures taken during program hours may be used for future promotional purposes. The LTC/Lakewood Center does not provide any medical insurance for any participant in any program.
Signature_________________________________	Date_____________________

Make checks payable to LTC, PO Box 274, Lake Oswego, OR 97034