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Education Center

Mime Technique Intensive

ages 18 and up

Friday, April 17 from 6:00 - 9:00pm; Saturday, April 18 from 10:00am - 6:00pm; and Sunday, April 19 from 10:00am-6:00pm

Silver Spring Education Center
925 Wayne Ave, Silver Spring, MD 20910

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Participant's Information

First Name:

Last Name:

Gender:

Pronouns (for ex. He/Him/His; She/Her/Hers; They/Them/Theirs):

Date of Birth:

Nickname or Preferred Name (if different):

Primary Phone Number:

Primary Email for all class communication:

Emergency Contact Information

Emergency Contact Name:

Emergency Contact Phone:

Relationship to Participant:

If the participant has SEVERE allergies that we should be aware of, please list them below.

Does the participant regularly take any medications that we should know about? If yes, please list below. If no, please write 'none'.

In order to best serve each student, please list all physical, psychiatric, cognitive, medical, emotional, learning needs, behavioral challenges, other special needs, or anything else you would like us to know. This information is invaluable to providing a positive camp experience. Indicate any activities that have been discouraged or limited by participant's physician. Please help us serve you by being specific:

How did you hear about this class?:

REFUND POLICY:

I understand a full refund will be made when a program is cancelled due to insufficient enrollment. A full refund, minus a $25 processing fee is available if the participant is withdrawn at least 30 days prior to the start date of the program. A 50% refund is available if withdrawing less than one month but more than two weeks prior to a program's start date. No refunds will be made within two weeks of program's scheduled start date and/or after a program has begun.

Yes I understand and accept the Refund Policy

MEDICAL WAIVER:

In the event of an emergency, I give my permission to Round House Theatre to secure and administer treatment, including hospitalization, for the participant as named on this form.

Round House assumes no liability for injuries or damages arising from participation in any class or program. Due to the strenuous nature of some activities, the participant is encouraged to consult a physician concerning fitness to participate.

Yes I understand and accept the Medical Waiver

Media Release

I understand that by completing this form Round House Theatre has my permission to use the image of participant as named on this form in publicity about Round House Theatre. If I do not wish Round House to use image of participant for publicity, I understand I must contact Education@RoundHouseTheatre.org to make this request.

Yes I understand and accept the Media Release

Additional RHT Policies

Rules and guidelines are intended for the safety and protection of all children and staff. Please review our Participant Code of Conduct with your student. If negative behavior persists, RHT will consult with parent/guardian. If a student is unable to correct behavior which is dangerous or disruptive to the program, suspension or dismissal from the program may occur.

Yes I understand and accept the additional Round House Policies

Adult Classes

Mime Technique Intensive

Available Groups

Available Sections

Class Place $250.00

Class Place $250.00

Participant's Information

Emergency Contact Information

*The Box Office is open Tuesday-Friday 12pm-5pm.

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Adult Classes

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Mime Technique Intensive

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Available Groups

Available Sections

Quantity for General Admission

Class Place $250.00

Quantity

Class Place $250.00

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Participant's Information

Emergency Contact Information