Emergency Parent Contact Information:
Medical Information & Release
Allergies:
Parent/Guardian Information:
Mother
Father
Emergency Contact Information:
RELEASE, ASSUMPTION OF RISK, AND CONSENT TO MEDICAL TREATMENT
I, the undersigned participant in the Dream Performing Arts Academy, or the parent/guardian of the above listed participant in the Dream Performing Arts Academy if he/she is under the age of eighteen, acknowledge and fully understand that each participant in the Dream Performing Arts Academy will be engaging in activities that involve risk of serious injury, including permanent disability or death, which might result not only from the participant's action, inaction or negligence, but also the action, inaction or negligence of others and/or the condition of any premises (including but not limited to football fields), risks created by the forces of nature and hazards of travel by air, train, bus, automobile, and other means, including but not limited to walking and/or driving or being driven to and from rehearsals and other activities, and furthermore, that there may be other unknown risks that are not reasonably foreseeable at this time. Accordingly, I acknowledge, fully understand and agree that I assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, and hereby release, discharge, covenant to indemnify and not to sue The Dream Performing Arts Academy, its instructors, managers, staff and associated personnel, officers, directors, agents, members, volunteers and representatives from any and all liability to the undersigned, his/her heirs and next of kin, against any and all claims by or on behalf of the participant as a result of the participant's participation in The Dream Performing Arts Academy. In an event of participant's illness, I hereby authorize any of the directors, officers, managers, instructors or chaperones of The Dream Performing Arts Academy who are present to consent to whatever x-ray examination, anesthetic, medical, surgical, or dental diagnosis, treatment, and/or hospital care that may be considered necessary for the participant in the reasonable judgment of the attending physician, surgeon, or dentist and to be performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing such medical or dental services. I agree to be financially responsible for the cost of such assistance and/or treatment. I recognize and agree that the directors, officers, managers, instructors or chaperones of The Dream Performing Arts Academy consenting to such health care may reasonably and in good faith rely upon the advice furnished to him or her by the attending licensed health care provider(s). I have read the above waiver/release and understand that I have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner without the express written consent of the Executive Director of The Dream Performing Arts Academy and that any unauthorized alteration will cause the participant to be removed from The Dream Performing Arts Academy.
NOTICE: THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE THE MEMBER MAY PARTICPATE IN THE DREAM PERFORMING ARTS ACADEMY. TREATMENT FOR INJURY WILL BE BASED UPON INFORMATION PROVIDED HEREIN. IF MEMBER IS UNDER 18 PARENTS OR GUARDIAN MUST SIGN FORM
The Dream Performing Arts Academy and/or the Dream Performing Arts Academy insurance companies are not responsible for any costs associated with treatment or prescriptions as a result of an illness or injury.
