Fillable LA JOLLA PLAYHOUSE POLICIES AND RELEASE FORM

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LA JOLLA PLAYHOUSE POLICIES AND RELEASE FORM

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LA JOLLA PLAYHOUSE
POLICIES AND RELEASE FORM
Please read ALL PAGES of this form and s
ign on reverse indicating you have read and agree to the Hold Harmless
S
tatement, Behavioral Policy, Photo Release, Medical Information & Accommodation and Emergency Treatment
Authorization.
Your child cannot stay at La Jolla Playhouse without having submitted these signature pages.
Hold Harmless Statement
I agree that my child __________________’s participation in activities associated with La Jolla Playhouse workshops
(the activities) while on La Jolla Playhouse premises is voluntary and at the sole risk of the undersigned. In
c
onsideration for my child being permitted to access and utilize La Jolla Playhouse premises, facilities and equipment
the undersigned agrees for themselves and their heirs and assigns to release and discharge La Jolla Playhouse, UC
San Diego and their respec
tive employees and contractors from any claim, demand, injury, cost, or liability, whether
resulting from the negligence of La Jolla Playhouse and/or UC San Diego or otherwise arising out of or resulting from
or incident to my child’s participation in the activities or the use of the premises, or any of its equipment or facilities in
connection with the activities. _____ (Initials)
Behavior Policy:
B
y participating in La Jolla Playhouse summer workshop, you agree to the terms of the Behavior Policy.
La Jolla Playhouse is committed to ensuring that all participants who attend YP@LJP programs are provided an
atmosphere where they can learn together free of harassm
ent or intimidation. Fun and safety are only possible when
there are behavior guidelines that all participants agree to follow. You and your child are advised to inform any
member of La Jolla Playhouse Education staff of any conduct that is offensive or that is in contradiction to La Jolla
Playhouse’s commitment to a harassment-free environment.
All participants are expected to show respect for lead teachers, teaching assistants, fellow students, Playhouse staff,
guests and facilities. Disruptive or dangerous behaviors and physical aggression are not acceptable. Our teaching
artists are professionals and they
will use sound, positive management tools within their classes. If any participant
does not respond to these measures, the participant will be escorted to the office for a time out. If the problem
behavior persists
, we will communicate with the parents or guardians and the participant may be removed from the
program with no refund of program fees. _____ (Initials)
Photo Release
During the course of our programs, we may take pictures/video of participants which may be used for publicity
purposes. By signing below, you authorize La Jolla Playhouse and its official representatives to use, without
obligation, photos or motion pictures of your child(ren), and/or their work for any and all print and electronic marketing/
publicity materials and the La Jolla Playhouse website. _____ (Initials)
Carpool and Safety Information
We encourage carpooling for your convenience and for the environment! If you carpool with friends, please
communicate clearly to your child who will be picking him/her up each day. If there are custody questions or
circumstances that we need to be aware of, please notify the education office in writing indicating the name(s) of the
person(s) and relationship to the participant. Please list the names and contact information for any person who has
your permission to pick your child up during the program:
NAME
PHONE NUMBER
Page 1 of 2: Your full signature is required on PAGE
2 of this form.
LA JOLLA PLAYHOUSE POLICIES AND RELEASE FORM
Hold Harmless, Behavior Policy, Photo Release, and
Confidential Medical/ Behavioral Information and Accommodation Form
Dear Parent/Guardian,
All children are welcome at La Jolla Playhouse (LJP) summer workshops. Please include any necessary
medical or behavioral information that will help us provide a safe and fun learning environment for your child.
This includes food and other allergies. This information will be used only as needed and solely by LJP. This is
a confidential form.
This form must be completed & signed in order for your child to participate in YP@LJP program.
Name of Participant/ Your child: _____________________________________________
Grade level of participant:_____________________________ Age: _____________________
Group enrolled in:______________________ School Attending: ________________________
Dates of participation:___________________________________________________________
Name of Parent/ Guardian (please print):____________________________________________
Phone number during program:___________________________________________________
Alternate phone number during program:___________________________________________
EMERGENCY CONTACTS (if we cannot reach the parent/ guardian above):
NAME PHONE # DURING PROGRAM RELATIONSHIP TO PARTICIPANT
1.
2.
Emergency Treatment Authorization
I hereby authorize any licensed physician, emergency medical technician, paramedics, nurses, hospital or
other medical or health care facility or provider (“Medical Provider”) selected by
the Playhouse to provide
medical care to the participant for any injury and/or condition that occurs, manifests or arises at any workshop
or program activities or related activities. I further authorize any Medical Provider to perform all procedures or
services deemed medically advisable to treat or relieve, or to attempt to treat or relieve any illness, injury,
and/or condition.
I acknowledge that there is a possibility of complications and unforeseen consequences in any medical
treatment, and I knowingly and voluntarily agree to assume such risk for and on behalf of said minor. I
acknowledge that no warranty is being made as to the result of medical treatment. I agree that
the participant is capable of participating in program activities except as otherwise noted below.
In addition, I agree to the terms of the hold harmless, behavior policy and photo release on page 1.
Medical or behavioral information that will help us provide a safe and fun learning environment for
Your child (if there are none that you are aware of, please indicate by writing NONE).
Signature of parent/guardian :_________________________________ Date: ________________
Page 2 of 2: Updated 2/2017
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Completed 12 October 2021

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