2018-2019 All-State FOR THE PARENT/GUARDIAN & TEACHER/SPONSOR: Tunderstand that students chosen for this production of IN THE HEIGHTS for the Annual 2019 Illinois High School Theatre Festival will be required to attend rehearsals at a location to be announced in July on: August 10*-12, August 31*-September 3, October 5*-8, November 23-25, December 27-29, and at the University of Illinois Urbana Champaign from January 7-12. I understand this student must attend all rehearsals as they are called. 1 agree to support this student's participation in this event in whatever ways I can. I understand there is a cost of $500 for participation in the All-State Production to assist in covering expenses such as meals, housing, and transportation at the Festival. (“denotes evening) Printed Name of Student: SCan Sole Bek ditap Volum —__ Sul8 Printed Name of Parent or Guardian Si (jf Parent or Guardian Date o/s Date jirector/Instructor Printed Name of Director/Instructor _ Sig) FOR THE PRINCIPAL: Thank you for allowing your student the opportunity to be a part of this invaluable experience. The All-State show is a production comprised of actors, technicians, and musicians from all over the state of Illinois. In the Heights will be presented January 10-12, 2019 at the 44th Annual Illinois High School Theatre Festival at the University of llinois Urbana-Champaign. There is a fee of $500 per student to cover expenses such as meals, housing, and transportation at the Festival. The staff is working tirelessly on obtaining donations and grants to offset and hopefully eliminate these costs for the students who need financial assistance. In the past many schools have provided partial or full funds if their student was selected to be a part of the All-State Company. We thank you for your consideration of this request. Ifyour school is able to provide financial assistance, please indicate your contribution in the space below: ——a full scholarship $500 __a ee $250 ___ other amount $. A. Erin Delog wi Lf, slza)ie Printed Name of School Principal Signature of SchoalPrincipal Date | Please obtain signatures, then scan and save as a .pdf Save as: LastName_FirstName SignaturesForm.pdf (Example: Smith John_SignaturesForm.pdf) You will be asked to upload this form to your on-line application. ‘SUBMISSION DEADLINE: May 25, 2018Ilinois DICAL, B) print legibly, » must complete a medical release form. Please type or Participant Name: _G@on Solem — Are you a (circle one): Student) All-State Production Staff Home Address: 5Y6 south Miithell Avene Gy, state,Zip: — Elmbucsi.Titineis 601.6 PhoneNumbers: Gho-syx-Tgus (630+ #05-3525 jome Cell Work Date of Birth: Tune 28 ava 05/28/03. Parent/Guardian First and Last Name (for students only}: Betsy Solemn School Name: Yor k School city: F IMhufst Emergency Contact: been Emergency Phone: 3) 248. — Home Cell Work Do you have insurance: Aes (ifyes, please indicate policy below) __No Health Insurance Company _( 9 Policy #0723271) OD List any Allergies to Medications WOW List any Medical Conditions. vv SIGNATURES: Participant refers to the student, chaperone, sponsor, or production staff member who is attending the Illinois High School Theatre Festival, and/or participating in the All-State Production of /n the Heights. Participants must sign on line A. Guardian, or next of kin must sign on line B. NOTE: All students participating, even if over the age of 18, must have a parent, guardian, or next of kin’s signed permission. Please read the following page carefully! --continued on next page2018-2019 ALL-STATE MEDICAL/LIABILITY RELEASE FORM - continued 1. The undersigned participant (student, chaperone, or sponsor) agrees to abide by Illinois High School Theatre Festival rules and regulations as posted on the Festival web page (wwwillinoistheatrefest.org) and in the Festival Program. The undersigned sponsor/parent/guardian/next of kin agrees to be responsible for the above named student while traveling to and from events including auditions, rehearsals, work days, Festival, etc, including any expenses incurred by the above named participant, caused by the above named participant, and/or any personal injuries which may occur to the above named participant. 2. Lunderstand that in case of serious injury, | hereby give my permission for emergency medical treatment, as recommended by a physician; I understand that no surgical procedure will be performed without my permission and consent; | understand that any medical expenses are my financial responsibility. 3. Ihereby release, acquit, and forever discharge the Illinois Theatre Association, its Board of Directors, Planning Committee Members, employees, agents, and representatives; the University of Illinois at Urbana Champaign, its Board of Trustees, employees, agents, and representatives; and Illinois State University, its Board of Trustees, employees, agents, and representatives, from any and all claims, causes of action, damages, or judgments, whether in contract or in tort, for any injuries including personal that may be incurred arising out of or in any way connected to the attendee's participation (signature and date required for participation). 4. Thereby release, acquit, and forever discharge hosting high schools, their school boards, officers, employees, agents and representatives from any and all claims, causes of action, damages, or judgments, whether in contract or in tort, for any injuries including personal that may be incurred arising out of or in any way connected to the attendees participation. a_Sangalom ate 5 ADI Signature of Participant (student, All-State production staff) B Date. 2-18 Signature ¢fParent, Guardian, or Next of Kin Please scan and save as a.pdf Save as: LastName FirstName MedForm.pdf (Example: Smith John MedForm.pdf) You will be asked to upload this form to your on-line application. SUBMISSION DEADLINE: May 25, 2018