Pizazz 2023 Application

Relationship

Emergency Contact's phone number

Area CodePhone Number

Name of Doctor

First NameLast Name

Doctor's phone number

Area CodePhone Number

List any physical limitations, developmental or learning disabilities and/or medical problems/allergies

Date of last Tetanus booster

Insurance Company

I/We, the undersigned parent(s)/guardian of __________, a minor, (continued below)

Fill in student's name above

do hereby authorize bona fide officials of the United Methodist Church Westlake Village, as agents of the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical treatment and hospital care deemed advisable by and to be rendered under the general or special supervision of any member of the medical staff or emergency room staff licensed under the provisions of the Medical Practice Act and on the staff of any acute hospital holding current license to operate a hospital from the State of California Department of Public Health.

It is understood that this authorization is given in advance of any diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his or her best judgment may deem advisable. It is understood that every effort shall be made to contact the undersigned prior to rendering treatment to the patient (except in the case of a life-threatening emergency), but that any of the above treatment will not be withheld if the undersigned cannot be reached. The Pizazz program or the United Methodist Church Westlake Village will not be responsible or held liable for the cost of such care.

This medical authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. It is to be in effect from July 24 - 28, 2023, while the student listed is participating in the Pizazz Music Camp.

Also, by signing this release, I agree to indemnify and hold harmless the United Methodist Church Westlake Village (UMCWV), the Pizazz Music Camp and/or staff/volunteers of both in case of any illness, injury, liability, expense or loss as a result of my child (listed above) participating in the Pizazz Music Camp at UMCWV.

PHOTO RELEASE

I agree that the above-named participant may be photographed or videotaped during the week of Pizazz Music Camp and that this photo/video may be used - without the participant’s name included - by UMCWV in publicity, i.e. brochures, church and Pizazz website and Facebook postings. I acknowledge that no further notice is needed by the church prior to the release of the photo/video.

Select ONE Photo Release response

Yes, I approveI approve, but only for use of the 2023 group photoNo, I do not approve (Please discuss with a coordinator)

Signature of Parent/Guardian (Use your mouse to sign name on line provided.)

Clear

Date signed

Date

Upon completion of this form, click submit, then return to the Pizazz Music Camp Applications/Brochure page and click on PayPal to make payment. PayPal will charge a small convenience fee ($5 or $7, depending on date submitted).

Pizazz 2023 Application

Pizazz Medical, Liability & Photo Release Form