ACTOR THERAPY INTENSIVE - REGISTRATION FORM

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Cell Phone *

Country

(###)

###

####

Required treatment for said diagnoses?

Option 1

Option 2

Should paramedics be called in an emergency? *

Yes

No

MEDICAL AUTHORIZATION *

In the event that my emergency contacts cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event I am injured or become ill.

Check here to authorize

MEDICAL EXPENSE AUTHORIZATION *

I understand that Actor Therapy will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility.

Check here to authorize

COVID-19 VACCINATION STATUS *

I am fully vaccinated against COVID-19

I am partially vaccinated against COVID-19 (one or more doses, even if not up-to-date)

I am not vaccinated against COVID-19 because of a legally recognized religious or medical exemption.

Other

PHOTO/VIDEO RELEASE *

I hereby give permission for my image to be photographed/recorded by Actor Therapy staff, and understand the photos/videos may be used for promotional purposes including flyers, brochures, newspaper and on the internet (as well as any mediums not specifically listed here). I understand that although my photograph may be used for advertising, my identity will not be disclosed, and I do not expect compensation. All photos and videos are the property of Actor Therapy and its affiliates.

Check here to authorize