Cathryn Sullivan'S Acting For Film Parental Consent And Release Of Liability (Page 3 of 3) in pdf

Cathryn Sullivan'S Acting For Film Parental Consent And Release Of Liability Page 3

Family Physician:

_______________________

Phone #:_____________________

Insurance Carrier: ______________________

Policy #: ___________________

Name of Insured: _______________________________________________________

Address:_______________________________________________________________

City/State/Zip: _________________________________________________________

Home Phone: ______________ Work Phone: _______________ Cell: ____________

Person Responsible for Charges (if different from above):________________________

Address:_______________________________________________________________

City/State/Zip: _________________________________________________________

Home Phone: ______________ Work Phone: _______________ Cell: ____________

Person to contact if Parent/Guardian is unavailable: ____________________________

Home Phone: ______________ Work Phone: _______________ Cell: ____________

______________________________

________________________

__________

Parent/Guardian Signature

Participant/Student Signature

Date

WAIVER FOR MINORS (Under 18 Years Old)

The undersigned parent and/or guardian does hereby represent that he/she is in fact,

acting in such capacity and agrees to save and hold harmless and indemnify each and

all of the parties referred to above from all liability, loss, cost, claim or damage

whatsoever which may be imposed upon said parties because of any defect in or lack of

such capacity to so act and release said parties on behalf of the minor and parents or

legal guardians.

_________________________ ______

________________________

________

Print Participant/Student Name Age

Signature of Parent/Guardian

Date

Cathryn Sullivan'S Acting For Film Parental Consent And Release Of Liability Page 3