Emergency Med Release - The Old Opera House printable pdf download

Old Opera House Studios

Emergency Contact and Medical Release Form

Student Name:____________________________________________ Date of Birth:____________________

I have been informed, and agree, that first aid will be administered, if necessary, by the Old Opera House staff

and volunteers, until parents/guardians, and/or medical care facilities can be reached.

All attempts will be made to contact the parent and/or legal guardian of any student prior to seeking medical

attention. If you are leaving your child at rehearsals, please have your cell phones turned on and with you at all

times.

I understand that the OOH instructors, staff, and volunteers are not medically trained. If a student is injured, or

has an illness, while participating in classes, rehearsals, and/or performances their response is limited to what an

average person might do to mitigate pain and further injury.

If a medical emergency arises, that requires medical care beyond simple first aide; I give the Old Opera House

my permission to take my child to the nearest emergency facility to receive emergency medical care.

Parent/Legal Guardian Signature___________________________________________ Date:____________

List of Emergency Contacts, in order of calling:

1._______________________________ Phone: __________________ Relationship: ______________

2._______________________________ Phone: __________________ Relationship: ______________

3._______________________________ Phone: __________________ Relationship: ______________

Medical Overview:

Food or Drug Allergies: _______________________________________________________________________________________

Date of last Tetanus shot: _______________________________

Medications student is currently taking: _________________________________________________________________________

Student has permission to take the over the counter medications as needed (please circle):

Yes

Physician’s Name: ______________________________________________ Physician’s phone: ___________________________

Please use the rest of this form for any information you feel we should know or to provide additional details to any of your answers

(Any known physical, behavioral, emotional, or mental health issues, about which we should know?):

___________________________________________________________________

Model Release Clause

I grant to The Old Opera House Theatre Company the right to take photographs of my child in connection with

their operations. I agree that the Old Opera House Theatre Company may use such photographs of my child

with or without his or her name for any lawful purpose, including for example such purposes as publicity,

illustration, advertising, and Web content.

____________________________________________________________________________________________________________

Signature of Parent or Guardian

Date

Emergency Med Release - The Old Opera House