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1101 Sixth Street SW
Washington, DC 20024
 

In Partnership with:

The Wendt Center for Loss and Healing

4201 Connecticut Avenue NW, #300
Washington, DC  20008

Release Form

During the Voices of Now rehearsals, performances, workshops, talkbacks and related activities, pictures and/or videos will be taken. Your child will also engage in dialogue and writing activities as part of the Voices of Now creation and evaluation process. We are requesting your permission to capture your child’s image in these educational and performance environments and utilize your child’s written and spoken contributions as part of the play and film creation, program evaluation and promotion process.
 

In filling this form, you hereby grant consent to Arena Stage and the Wendt Center for Loss and Healing for the participation in interviews, the use of quotes and writing, and the taking of photographs, movies or video tapes of your child. Such use includes the display, distribution, publication, transmission, or otherwise use of program writing, photographs, images, and/or video taken of your child for use in materials that include, but may not be limited to, printed materials, newsletters, videos, classroom materials or other program-related purposes. You also hereby release Arena Stage and the Wendt Center from all claims, demands, and liabilities in connection with the above.  
 

Policies  .  

If the participant is under 18, I or another responsible adult will be present in the room or within calling distance while my child is participating in virtual instruction.  

I give permission for the participant's image and artwork to be used as positive examples of work created in Arena Stage and Wendt Center virtual programs in future materials such as brochures, the Arena Stage or Wendt Center websites and other applications. The participant will not be identified by name without my permission.  

No hate speech, discrimination, or bullying (including cyberbullying) is allowed in Arena Stage or Wendt Center programming, video chats, or communications of any kind. Cyberbullying can occur through SMS, text, and apps, or online in social media, forums, or gaming where people can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative, harmful, false, or mean content about someone else. It can include sharing personal or private information about someone else causing embarrassment or humiliation. Some cyberbullying crosses the line into unlawful or criminal behavior. Bullying of any kind, including cyberbullying, may result in expulsion from the program with no refund provided. If participant is under 18, I will discuss proper online conduct with my child. 

Arena Stage and the Wendt Center assumesno liability for injury or damages arising from the result of participation in classes, workshops, camps or programs.

To the best of my knowledge, there are no physical or other conditions that may interfere with participation that I have not already disclosed.  

I affirm that I have read and agreed to these policies.

I Agree

Please select who will be participating in Arena Stage's Voices of Now Virtual Program
AdultMinor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
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First Artist's Name

First Name*

Middle Name

Last Name*

Phone*
First Artist's Date of Birth*
First Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
First Artist's Signature*
Second Artist's Name

First Name*

Middle Name

Last Name*
Second Artist's Date of Birth*
Second Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Third Artist's Name

First Name*

Middle Name

Last Name*
Third Artist's Date of Birth*
Third Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Fourth Artist's Name

First Name*

Middle Name

Last Name*
Fourth Artist's Date of Birth*
Fourth Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Fifth Artist's Name

First Name*

Middle Name

Last Name*
Fifth Artist's Date of Birth*
Fifth Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Sixth Artist's Name

First Name*

Middle Name

Last Name*
Sixth Artist's Date of Birth*
Sixth Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Seventh Artist's Name

First Name*

Middle Name

Last Name*
Seventh Artist's Date of Birth*
Seventh Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Eighth Artist's Name

First Name*

Middle Name

Last Name*
Eighth Artist's Date of Birth*
Eighth Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Ninth Artist's Name

First Name*

Middle Name

Last Name*
Ninth Artist's Date of Birth*
Ninth Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Tenth Artist's Name

First Name*

Middle Name

Last Name*
Tenth Artist's Date of Birth*
Tenth Artist's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Artist's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
For parents of participants under 18: I affirm that I have read and agreed to these policies.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Are there any special learning needs, health information, accommodations or other information we should be aware of for an online program?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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