Student Sign Up!

Student's First Name*

Student's Last Name*

Student's Grade Level*

Student's Age*

Student's Birthday*

Mailing Address*

Guardian's Name*

Guardian's Email Address*

Guardian's Phone Number*

(Additional) Guardian's Name

(Additional) Guardian's Email Address

(Additional) Guardian's Phone Number

Does your student have any allergies or medical conditions that might be helpful for us to be aware of? *

Is there anything else we should know in order to offer your student the best experience possible? *

Sometimes we get some fabulous candid photos of students performing on stage or in class and we'd love to be able to share those. STUDENT PHOTO RELEASE: I do hereby give ACT UP!, the irrevocable right to use my child's name (or any fictional name), picture, portrait or photograph, likeness, voice and words in all forms and media and in all manner, for advertising, trade or in any other lawful purpose for the benefit of ACT UP! I hereby forever waive any right to inspect or approve the finished product, including but not limited to, written copy and/or an image in print or on a web site, television, radio, film, newspapers, magazines and other media, and in any form, that may be created in connection therewith now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. I understand that ACT UP! cannot control the unauthorized use by persons others than ACT UP!, of my name or image once such name or image is published. Any claim I may have concerning unauthorized publication of my name and image may be pursued by me against the unauthorized user. ACTUP!, disclaims any responsibility for such unauthorized use of my published name or image. I hereby agree to release, defend, discharge and hold harmless ACT UP! and its agents, officers, or employees, and all persons acting under its permission or authority, from and against all claims, damages, or liability arising from or related to the use of all images. I have had sufficient time to review and seek explanation of the provisions contained above and have carefully read and understand them, and agree to be bound by them. I voluntarily and irrevocably give my consent and agree to this Release and Waiver*

Yes

Student Sign-up Form

(646) 764-6349

Logan@ActUpTogether.com