Play with Grace, LLC

“TAKING FLIGHT” EXPRESSIVE DRAMA

 “TAKING FLIGHT” EXPRESSIVE DRAMA PROGRAM

  We are happy to enroll (participant name)

_____________________________________________                                                                                                                                            in our “Taking Flight” Expressive Drama program, scheduled to begin on September 25, 2012.

Participant Agreement

I, ____________________________________________ (full name of participant) will be attending

 ___alone  /  ___with support person(s)

_________________________________________________________________(name or names of those providing support)  the “Taking Flight” Expressive Drama winter program scheduled weekly from September 25 - December 8, 2011.

I will be transported to the Play with Grace theater by:

 _________________________________________________________ (full name of person/organization providing transportation if different than the support person).

Play with Grace, LLC shall provide instruction in Expressive Drama as outlined in our “Taking Flight” brochure, and scheduled weekly September 25 - December 8, 2012. I agree to attend all sessions, including rehearsal and performance unless I have notified the Play with Grace staff that I cannot attend. I understand that payment for these sessions (whether or not I am present) is non-refundable.

Payment of $400 (four hundred dollars) for this workshop must be made payable to Play with Grace, LLC prior to October 5 and sent to PLAY WITH GRACE, LLC, 57 Olive Street, New Haven, CT 06511. 

___Enclosed is my Check or Money Order for $400 made payable to Play with Grace, LLC    

 ___Please bill $400 to my Credit Card

Name on Credit Card:___________________________  

Type of Card: ___ MC ___ Visa  ___ DISCOVER___ Amex Credit Card No:_______________________________

Exp. Date_______/_______  Security Code #:________

If there are any medical conditions we should be aware of, please provide detailed information (guardian’s explanation or physician’s note) with any special arrangements Play with Grace staff must make to accommodate and insure your safety and well-being.

___No, there are no medical considerations       

 ___Yes, there are medical considerations (please see enclosed, attached information)

My contact information:

      __________________________________________________________________ PARTICIPANT NAME                                                                                                           

___________________________________________________________________________________________________________ PARTICIPANT SIGNATURE

___________________________________________________________________________________________________________ NAME OF ORGANIZATION / PARENT / GUARDIAN

___________________________________________________________________________________________________________STREET STREET ADDRESS

___________________________________________________________________________________________________________STREET CITY STATE ZIP                                           

___________________________________________________________________________________________________________STREET  HOME/WORK/CELL PHONES

___________________________________________________________________________________________________________STREET EMAIL ADDRESS

___ I am my own guardian         ___I have a legal guardian (identified below) 

     ________________________________________________________________                     GUARDIAN NAME                                                                 

________________________________________________________________                     GUARDIAN SIGNATURE        

___________________________________________________________________________________________________________GUARDIAN’S HOME/WORK/CELL PHONES                    

________________________________________________________________                    EMAIL ADDRESS

PLEASE CONTACT US BY PHONE OR EMAIL TO REQUEST A PARTICIPANT CONTRACT AND WE WILL PROMPTLY PROVIDE ONE TO YOU.

IF YOU CHOOSE TO USE THE AGREEMENT ON THIS WEBSITE SIMPLY CUT AND PASTE COPY TO YOUR OWN COMPUTER AND SEND US (BY "SNAIL MAIL" -- WE NEED THE SIGNATURES) WITH THE REQUESTED INFORMATION.

MANY THANKS!

AND WE LOOK FORWARD TO MEETING YOU!