Broadway South Dance Studio Medical Release Form

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Please return to Office Manager at time of registration
Broadway South Dance Studio Medical Release Form
I, _________________________________ (parent/guardian’s name), hereby give
permission for any and all medical attention to be administered to my child,
_________________________________ (child’s/children’s name(s)), in the event
of an accident, injury, sickness, etc. under the direction of the physician(s) listed
below or at any necessary emergency facility, until such time as I may be
contacted. I also assume the responsibility for the payment of any such treatment.
This release is effective at least to the end of the dance season following the
current season, but for not less than a period of one year from the date given
below.
Street address: _____________________________________________________
City: ________________________ State: ________ Zip Code: _____________
Home Phone: ______________________
Cell Phone: ____________________
Work Phone: ______________________
Insurance Company: ________________________________________________
Policy Number: _______________________________________
Child’s Physician: ___________________________________________________
Street address: _____________________________________________________
City: ________________________ State: ________ Zip Code: _____________
Physician’s Phone: ___________________________
Known Allergies & Existing Medical Conditions: _________________________
__________________________________________________________________
Emergency Contact Phone Numbers: __________________________________
Parent/Guardian Signature: __________________________________________
Date Signed: _________________

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