Milligan Productions (Team Broadway/StageRight Programs) 2023 Paperwork

Milligan Productions (Team Broadway/StageRight Programs) 2023 Paperwork

Contact/Required Info, Liability Release, and Medical Release Forms
Student Name:*

First NameLast Name
Student's Birthdate:*

MonthDayYear
Date
Student Gender:*

FemaleMale
Parent/Guardian Name:*

First NameLast Name
Additional Parent/Guardian Name (Optional):

First NameLast Name
Best Email Address*
example@example.com
Parent/Guardian Phone Number:*
Please enter a valid phone number.
Do you receive text messaging?*

YesNo
Please list the class(es) you/your student are enrolled/enrolling in:
Please list any other information we need to know (allergies, medical conditions, prior experience, concerns, additional contact info, etc.):
Please review "LifeHouse Productions: Policies & Background" document HERE.

Please review the "Milligan Productions Important Info/Policies" document HERE.
Please confirm your agreement to the following:
I acknowledge that I have read and gone over with my student the “LifeHouse Productions: Policies & Background” document and the "Milligan Productions Important Info/Policies" document, and agree that my student(s) and I will abide by the polices set forth therein.*

I acknowledge
I agree that pictures & video footage of my student(s) may be used by Milligan Productions & LifeHouse Productions for publicity purposes such as (but not limited to): advertising the end of session performances & promoting upcoming classes.*

I agreeI do not agree
I understand that Milligan Productions and LifeHouse Productions cannot control what others do in regards to pictures and video footage of classes and performances (i.e. posting on social media), and are therefore not responsible in any way in this regard.*

I agree
I understand that Milligan Productions does not generally offer refunds or cancellations. Milligan Productions may, at their sole discretion, offer class credit for a future session (within one year) or a refund if services were paid for with cash or Credit/Debit card. Charter School students may request a cancellation of their PO prior to the service start date. After the start date, we do not offer refunds or cancellations, except for in cases of classes canceled by Milligan Productions and not through the fault of the students.*

I agree
Signature of parent/guardian (or participant if over 18):*

Clear
Signer's Name:*

First NameLast Name
Date of Signing:*

MonthDayYear
Date

RELEASE OF LIABILITY

MILLIGAN PRODUCTIONS & LIFEHOUSE PRODUCTIONS
Participant's Name*

First NameLast Name
I understand that there are risks of physical and emotional injury associated with, arising out of, and inherent to the activity of dance and performing arts. I also understand that by participating in classes, performances, and events, I increase the risk of catching illnesses including COVID-19. In recognition of this acknowledged risk of injury and illness, I knowingly and voluntarily waive all right and/or causes of action of any kind, including any and all claims of negligence arising as a result of such activity from which liability could accrue to Milligan Productions and/or LifeHouse Productions, or their officers, agents, employees, instructors, contractors, volunteers, subsidiaries, parent corporations, and all affiliated entities (hereinafter collectively referred to as “Milligan Productions and LifeHouse Productions”).

I hereby agree to release Milligan Productions and LifeHouse Productions and hold Milligan Productions and LifeHouse Productions harmless of all liability, and hereby acknowledge that I knowingly and voluntarily assume full responsibility for all risks of physical and emotional injury arising out of active participation in dance and/or performing arts on behalf of the participant.

I am aware that this is a release of liability and an acknowledgement of my voluntary and knowing assumption of the risk of injury. I have signed this document voluntarily and of my own free will in exchange for the privilege of participation.

In the case of the student being a minor, I confirm that I am the parent and/or legal guardian of said student, and I agree to release Milligan Productions and LifeHouse Productions from any and all such liability described above as it pertains to myself, my student, and all others I may be associated with. I acknowledge that I am knowingly and voluntarily assuming all risks of injury inherent to these activities on behalf of my student/ward.

The participant has my permission to participate in Milligan Productions and LifeHouse Productions events. I warrant the below information is complete and correct. I further release Milligan Productions and LifeHouse Productions of all liabilities associated with my child’s attendance at Milligan Productions and LifeHouse Productions events and classes.
Please confirm that you have read, understand, and agree to the above release of liability form.*

I confirm
Date*

MonthDayYear
Date
Signature:*

Clear
Signer's Name:*

First NameLast Name
Date

MonthDayYear
Date

AUTHORIZATION TO CONSENT OF MEDICAL TREATMENT

MILLIGAN PRODUCTIONS & LIFEHOUSE PRODUCTIONS
Participant's Name:*

First NameLast Name
I do hereby authorize Milligan Productions and LifeHouse Productions, as agents for undersigned, to consent to any x-ray examination, anesthetics, medical or surgical diagnosis or treatment and hospital care which is deemed advisable or necessary by, and is to be rendered under, the general or special supervision and upon advice of a physician and a surgeon licensed under the provision of the Medical Practice Act, or to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered by a dentist licensed under the provisions of the Dental Practice Act. It is understood and agreed that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our agent, Milligan Productions and LifeHouse Productions to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable or necessary. This authorization is given pursuant to the provisions Section 25.8 of the Civil Code of the State of California. This authorization is effective for a period of one (1) year from the date said authorization is signed.
For Minor:
In addition to my consent for the above, I/we give full consent for my child/ward, a minor, to attend any event sponsored by Milligan Productions and/or LifeHouse Productions. I/we agree not to hold the staff, agents, volunteers, or advisors of Milligan Productions or LifeHouse Productions responsible, nor liable in any way for accidents or injuries incurred while on an outing away from LifeHouse facilities or at an event on the grounds of LifeHouse or at the LifeHouse Studio. I/we also acknowledge that it is my responsibility to encourage and communicate to my child the need for his/her safe behavior and conduct on all such activities. I/we acknowledge that I/we have specifically represented to Milligan Productions and LifeHouse Productions that I/we are the parent(s) or legal guardian(s) of the aforementioned minor, having legal custody of said minor.

For Adults:

In addition to my consent for the above, I also agree not to hold the staff, agents, or advisors of Milligan Productions or LifeHouse Productions responsible, nor liable in any way for accidents or injuries incurred while on an outing away from LifeHouse facilities or at any event on the grounds of LifeHouse or LifeHouse Studio.
*PLEASE COMPLETE ALL INFORMATION BELOW (MINORS AND ADULTS)*

MEDICAL INSURANCE INFORMATION (if uninsured, or the following questions are not relevant, please write N/A in answer boxes).
Health Insurance Company Phone Number:
Health Insurance Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Plan Number:
Group Number:
Family Doctor Name:
Doctor Emergency Phone Number:
Please enter a valid phone number.
Hospital:
Emergency Hospital Number:
Please enter a valid phone number.
Please list any medical problems you/your child may have:
Persons to contact in case of emergency (please list at least two, and include name, phone number, relationship, and address):*
Authorized person(s) to pick up student beside parents (please include name, phone number, relationship, and address). Also please specifically list and label anyone forbidden from picking student up (such as in a custody/court order situation):*
*

By checking here I certify that, as parent/guardian of this participant or as a participant myself, I do consent to his/her/my waiver and release as set forth above. I hereby give Milligan Productions Leadership and LifeHouse Leadership permission to authorize medical treatments for my child/myself listed above in the event of any emergency.
Date*

MonthDayYear
Date
Signature*

Clear
Signer's Name:*

First NameLast Name
Should be Empty:

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Milligan Productions (Team Broadway/StageRight Programs) 2023 Paperwork

RELEASE OF LIABILITY

AUTHORIZATION TO CONSENT OF MEDICAL TREATMENT