STUDENT’S NAME:
M / F
BIRTHDATE: MM / DD / YY
GUARDIAN’S NAME:
STUDENT’S AGE:
SCHOOL:
GRADE:
MAILING ADDRESS:
HOME PHONE #:
GUARDIAN’S WORK #:
PHYSICAL ADDRESS:
GUARDIAN’S CELL #:
mandatory, please complete
STUDENT’S CELL #:
GUARDIAN’S E-MAIL:
STUDENT’S E-MAIL:
1. Have you ever participated in a Pistarckle Theater activity? Circle: YES
NO
2. If yes, list any Pistarckle Theater activities or productions you have participated in:
3. Have you ever performed for others before?
Circle: YES
(for example, a play, dance performance, talent show, speech, etc.)
NO
4. If yes, list the type of performances you have done?
5. What are your talents or interests?
(for example, acting, dancing, singing, sports, clubs, hobbies, etc.)
On a scale of 1 to 10, please tell us how much you like: (10 is the highest)
6. Acting & Storytelling:
1 2 3 4 5 6 7 8 9 10
7. Dancing:
1 2 3 4 5 6 7 8 9 10
8. Shakespeare:
1 2 3 4 5 6 7 8 9 10
9. Painting & Drawing:
1 2 3 4 5 6 7 8 9 10
10. Reading & Writing:
1 2 3 4 5 6 7 8 9 10
11. Designing Hair & Make-up:
1 2 3 4 5 6 7 8 9 10
12. Building Costumes, Props & Sets:
1 2 3 4 5 6 7 8 9 10
13. Learning how to run Lights & Sound:
1 2 3 4 5 6 7 8 9 10
14. Stage Managing:
1 2 3 4 5 6 7 8 9 10
15. Other Specialties:
1 2 3 4 5 6 7 8 9 10
(for example, gymnastics, poetry writing, instruments, etc.)
16. Why did you decide to participate in a Pistarckle Theater activity?
17. What do you hope to learn during this activity?
18. How comfortable are you speaking in front of others?
19. Do you have any formal acting, dancing, singing, or musical training?
20. Have you ever been to a play or a musical?
21. If so, what play or musical was it?
22. Where (at school, Pistarckle Theater)?
23. Do you have a favorite play?
24. A favorite movie?
25. A favorite book?
GUARDIAN COMMITMENT:
I have read the Policies and Starz Participation Agreement with my child and give my word to do my
best to achieve what has been asked of me.
Yes
No
I agree that my child’s picture may be used in promotional materials.
Yes
No
I will pay any tuition or fees involved. I understand that failure to do so will put my child’s privilege to perform
in jeopardy.
Yes
No
I consent to my child being given ibuprofen or Tylenol, upon their request. Yes
No
Are there any allergies, health issues, or previous injuries we should be aware of?
STAR signature: __________________________________________
Date: ____________
Guardian signature: _______________________________________
Date: ____________
Education Director signature: ________________________________
Date: ____________