3rd-5th grades - Storytelling Through Dance - Oregon Ballet Theatre
3rd - 5th grades
Da Vinci Middle School
August 2nd - 6th
9:00am - 3:00pm

This week long workshop is for all students who like to move and groove, tell stories, and most important DANCE!  Each day includes a ballet class, creative movement and improvisation, and culturally specific dance from around the world.  Students will learn about many different forms of dance and celebrate the diversity of people and stories who have shaped this evolving art form.  Most importantly, students will get to share their own stories through movement!
Sign in to Google to save your progress. Learn more
Email *
STUDENT INFORMATION
Student's Name: *
Student's School: *
Student's grade in fall 2021: *
Student Address: *
Please list any food or medicine allergies, if none please state none: *
If you would like to include additional child/family information.  Examples of helpful information might include custodial arrangements, restraining orders, family circumstances affecting attendance or tardiness, etc.
Student Racial Demographic (optional):
Clear selection
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name: *
Phone Number: *
Phone Text: *
Parent/Guardian Email: *
EMERGENCY CONTACT INFORMATION - other than parent/guardian
Emergency Contact Name:
Emergency Contact Relationship to Student:
Emergency Contact Phone:
MEDICAL RELEASE
This information is to help the OBT Education and Community Engagement/OBT, and their authorized agents seek medical attention for your student should you be unavailable in the event of an injury or emergency. We will make every effort to contact you, or a designated alternate, in the event of an emergency. This form provides our staff with the authorization necessary to treat or seek treatment for your student should an accident occur while in the care of OBT. Furthermore, this authorization will be used in the event that emergency or hospital care becomes necessary.
Parent/Guardian Authorization:
The student herein described has permission to engage in all prescribed activities, except as noted by me, either individually or on the advice of a physician. The student’s history is correct and complete to the best of my knowledge. I hereby grant permission to the OBT Education and Community Engagement /OBT’s company physician and physical therapy staff (or in the event of emergency room care, the attending physician and/or ER staff) to order x-rays, routine tests, and/or treatment for the health of my student. In the event I cannot be reached in an emergency, I hereby grant permission to the physician selected by the OBT Education and Community Engagement /OBT to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my student, as named above.
By checking the box below I have read and consent to the Parent/Guardian Authorization. *
Required
MEDICAL CONTACT INFORMATION
Student's Physician: *
Physician's Phone Number: *
Student's medical insurance company.  If student does not have medical insurance please write N/A. *
Group # and Responsible Party:
Hospital of Choice (This choice may not be accommodated due to the nature/severity of the injury or due to time restraints with respect to receiving immediate care.): *
STUDENT'S MEDICAL HISTORY
List medications currently taken (If student does not take any medications, write N/A): *
List allergies (to medication, foods, etc. If student does not have any allergies, write N/A): *
*Does the student have any medical condition, illness, or injury of which we should be aware, i.e.,allergies, ADD/ADHD diagnosis, any orthopedic injury, chronic illness, medication use on site, etc. (If student does not have any medical conditions, illnesses, or injuries, write N/A): *
Student must be signed in and out by a parent/guardian or other responsible adult each day.  Student will wait outside with OBT staff until properly signed out.  Please list all authorized adults that may sign student out.   *
OBT STORYTELLING THROUGH DANCE EXPECTATIONS
1.  Students must wear a mask at all times.
2.  Students must complete daily health questionnaire and temperature checks before entering class.
3.  Class begins promptly at 9:00am.  Students arrive on time and prepared for movement.
4.  Students are encouraged to wear comfortable clothes that they may move freely in and to bring layers, as it is often cool in the dance studio and auditorium.
4.  Students are encouraged to bring a full water bottle each day.
3.  Students are to be respectful of teachers, each other and self at all times.

*
Required
STUDENT PHOTO RELEASE
OBT shall have the absolute sole and perpetual right and permission to use, publish and/or reproduce in any form or any manner, photograph, film, videotape, audiotape, digital recording, or any other form of representations in which the publicity during the term of this Agreement shall be under OBT’s sole control. *
Required
STUDENT LIABILITY WAIVER
It is agreed that I, my child, adopted or otherwise, and my heir and executors, waive and release all rights and claims for damages that I may have at any time against OBT, its representatives whether paid or volunteer, for any injury or damages in connection with OBT’s curriculum or other activities related to OBT. The risks involved with respect to such a program are fully understood. I authorize OBT and its employees or agents to provide or secure emergency medical treatment for me or my child on my behalf if deemed necessary. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms