Name: Envision Technology Advisors
Price range: $

Child's First Name

Child's Last Name

Age

Child's School

Address

City

Zip Code

Phone

Parent/Guardian Name(s)

Parent/Guardian Email

Parent/Guardian Phone

Child's Allergies

If none, write "None"

Does the student carry an epipen? YesNo

Emergency Contact Name(s)

Emergency Contact's Relationship To Student

Emergency Contact's Phone

Authorized Pick Up Options

Please list anyone to whom your child may be released for pick up.

How did you hear about us?

I accept that the Stadium may take photos of my child, which may be published online, or in print.

Please read the release below and check the box if you agree In consideration of my child being permitted to participate in the program, I hereby release, waive, and discharge the Stadium Theatre, its directors, employees, and volunteers (collectively the "Stadium Theatre") from liability from any and all claims arising from negligence of the Stadium Theatre. I further agree to hold harmless, defend, and indemnify the Stadium Theatre against any and all claims arising from my child's injury or loss due to my child's participation in the program, including the inherent risks of the program activities and those arising from negligence of the Stadium Theatre. I authorize the Stadium Theatre to arrange for medical treatment for my child in the case of an emergency.

Course Registration