Emergency Contact Form - Livingston Arts printable pdf download

Emergency contact form for minors attending programs

at Livingston Arts without parent supervision

Authorization for the emergency treatment of a minor

I understand that in cases of injury or illness, the quickest medical aid will be summoned

and first aid administered if necessary. In the event that I, the parent of the child named

below, cannot be reached in an emergency, I hereby give permission to the physician

selected by the Genesee Valley Council on the Arts administrator to X-ray, hospitalize,

secure treatment for and order injection, anesthesia, surgery or dental care for

My Child’s Full Name _______________________________________________________

If hospital or emergency room attention is required, please use the facilities of

______________________________________ hospital, if possible.

Physician’s Name__________________________________________________

Dentist’s Name____________________________________________________

Special medical conditions to be aware of (allergies, medications, disabilities, etc.):

As the parent of the child named above, I can be reached at the following:

Home phone number_________________________

Work phone number__________________________

Cell phone number(s)_________________________

As a parent I understand that children occasionally get hurt or become ill even under the

supervision of capable adults and accept the risk inherent in sending my child to a

program at Livingston Arts Center. If this form is incomplete or not submitted, I

understand that my child will not be able to participate in the program for which he/she is

registered.

________________________________________________________________________

Parent signature

Date

____________________________________________________

Print Parent name

Please check one:

I give GVCA permission to include my child in publicity photographs ______

I DO NOT give GVCA permission to include my child in publicity photographs ____

Emergency Contact Form - Livingston Arts