Child's Information Child's First Name Child's Last Name School Grade Completed -select one- 3 4 5 6 7 8 T-shirt Size -select one- Kids Small Kids Medium Kids Large Adult Small Adult Medium Adult Large Adult X-Large Optional Orders for make-up kits need to be submitted by Jun 3, 2025. Stage Make-up Kit Optional: + $27.00 -select one- Fair/Lightest Makeup Kit PK0 Fair Light/Medium Makeup Kit PK1 Fair Medium/Tan Makeup Kit PK2 Fair/Medium Olive Makeup Kit PK3 Deep Olive Makeup Kit PK4 Light Brown Makeup Kit PK45 Medium Brown Makeup Kit PK5 Dark Brown Makeup Kit PK6 Each makeup kit includes the following: 1 creme foundation, 1 creme contour palette (highlight, shadow, rouge, lip color), 1 face powder, 1 eye pencil, 1 flat brush, 1 powder puff, 1 sponge applicator and 1 stipple sponge. Parent Information First Name Last Name Phone Email Alternate Emergency Contacts If I cannot be reached via the contact information above, I authorize the staff members of GILT Jr. to contact the following people as our alternate emergency contacts: Primary Emergency Contact Primary Emergency Phone Primary Emergency Address Primary Emergency City, St Zip Secondary Emergency Contact Secondary Emergency Phone Secondary Emergency Address Secondary Emergency City, St Zip Medical Information Physicians Name Physicians Phone Insurance Company Policy Number Allergies or Special Health Conditions I Authorize: all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver only applies in the event that neither parent/guardian can be reached in the case of an emergency. Photo Release / Media Waiver For good and valuable consideration, the receipt of which is hereby acknowledged, I, , hereby authorize Grand Island Little Theatre (hereinafter “GILT”) to use the likeness of me and/or my minor child(ren) (listed below) in a photograph in any of its publications, including but not limited to GILT’s printed and digital publications. I understand and agree that any photograph using my and/or my minor child(ren)’s likeness will become the property of GILT and will not be returned. I acknowledge that since my and/or my minor child(ren)’s participation with GILT is voluntary and done with my consent, neither I nor my minor child(ren) will receive financial compensation for using my and/or my minor child(ren)’s likeness. For myself and on behalf of my minor child(ren), I irrevocably authorize GILT to edit, alter, copy, exhibit, publish, or distribute any such photos for publicizing GILT’s programs or for any related, lawful purpose. In addition, for myself and on behalf of my minor child(ren), I waive the right to inspect or approve the finished product, including physical or electronic copy, wherein my and/or my minor child(ren)’s likeness appears. Additionally, on behalf of myself and my minor child(ren), I waive any right to royalties or other compensation arising from or related to using such photographs. On behalf of myself and my minor child(ren), I hereby hold harmless and release and forever discharge GILT from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, assigns, or any other persons acting on my behalf, on the behalf of my minor child(ren), or on behalf of my or my child(ren)’s estate have or may have because of this authorization. Permission Granted for Photo Release / Media Waiver Billing Information Address City State ZIP Code Payment Information Amount Due: $52.00
