Staff/Intern

CONSENT/RELEASE FORM

Staff/Interns - please fill out the following:

Name:

First Name

Last Name

Generally, my health is...

If health is poor/fair, please explain:

List any medical conditions for which you are currently being treated.

Do you have any processing or mental health history of which we can be aware?

List any medications you are currently taking.

(Prescription medications or otherwise)

List any medications or substances to which you are allergic.

Please exclude food preferences (vegetarian, lactose intolerant, etc.)

Family Physician

First Name

Last Name

Family Physician's Phone

(###)

###

####

Family Physician's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company

Insurance Policy Number

Consent For Medical Treatment

For myself and/or on behalf of my participating minor, I hereby give permission for any physician, hospital, or health care facility to provide medical care, treatment and administer medication to participant as deemed necessary by a physician or Rich Theatre LLC.

Model Release

I(We) hereby authorize and consent that Rich Theatre LLC shall have the absolute right to copyright, publish, use, sell or assign any and all photographs, portraits or pictures, videotapes and/or sound recordings, or any part thereof, that have been taken of the student and/or cast member, or in which the student and/or cast member may be included in whole or in part. (Consent is required in order for the student and/or cast member to participate in auditions, rehearsals and/or public performances)

Consent to Use and Publication of Image

I hereby give Rich Theatre LLC the absolute, unconditional, and irrevocable right and permission to use my name and Participant’s name and to use, reproduce, edit, exhibit, project, display, copyright and publish, photographic images and/or moving pictures and/or videotape images of me and/or Participant, with or without voice, in which I and/or Participant are included, in whole or in part, photographed, taped, videotaped and/or recorded prior to, during and/or after the theatrical event and to circulate same in any and all forms and media for art and advertising, and I hereby consent to the use of all printed matter in conjunction therewith and waive all rights to inspect and/or approve drafts, finished products, and/or editorial, promotional and printed copy and soundtracks that may be used in connection therewith, and waive all rights to control any aspect of any production, alteration, use, distribution or disposition of said products, copy, and/or sound tracks and hereby discharge and agree to hold Rich Theatre LLC harmless and fully indemnify Rich Theatre LLC from and against any and all claims arising by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the production, processing, duplication, projecting, or displaying of said images of me and/or Participant, and from any and all claims for violation of any personal and all proprietary rights me or the Participant may have or may claim to have in connection with such images and with the production, alteration, use, distribution, and disposition thereof.

Release of All Claims

For and in consideration of participation in Rich Theatre LLC activities, I hereby acknowledge that we understand that there could be some risks involved, and we hereby assume all such risks. I hereby release Spring Branch Church, Rich Theatre LLC and all of its agents, employees, officers and directors from any and all risks, actions, causes of action, claims, demands, liabilities and obligations of any and every nature whatsoever, including, without limitation, for illness, personal injury, death, property damage, and personal or proprietary rights, and hereby hold Rich Theatre LLC harmless and agree to fully indemnify Rich Theatre LLC from and against any and all claims. I hereby personally assume full responsibility for any and all claims and for any and all hospital and medical bills for myself and/or Participant. I hereby certify to Rich Theatre LLC that I have obtained and will maintain in full force and effect adequate primary medical insurance for myself and/or Participant. In the event it is necessary for me or Participant to return home due to disciplinary action, for medical reasons, or otherwise, I hereby personally assume full responsibility for all such transportation arrangements and costs.

Intern Initials

Step 3: Behavior Agreement