School Group Request Form | Portland Center Stage

The email and phone number that you input will be our direct form of communication with you for all information regarding your minor. Please be sure to include an email that you will be checking frequently.

Contact Email*

Name of Minor*

First NameLast Name

Birth Date of Minor*

Date

Email of Minor (if applicable)

example@example.com

Guardian/Parent #1*

First NameLast Name

Guardian/Parent #1 Full Address*

Street Address

Apt/Unit

CityState / Province

Postal / Zip Code

Guardian/Parent #1 Phone number*

Please enter a valid phone number.Format: (000) 000-0000.

Guardian/Parent #2

First NameLast Name

Guardian/Parent #2 Full Address

Street Address

Apt/Unit

CityState / Province

Postal / Zip Code

Guardian/Parent #2 Phone number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Contact*

First NameLast Name

Alternate Contact Full Address*

Street Address

Apt/Unit

CityState / Province

Postal / Zip Code

Alternate Contact Phone number*

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Alternate Contact*

Allergies to medications?

If yes, please elaborate

Allergies (other, including food); please specify

If applicable, please note the conditions for which the child is currently receiving treatment or medication

YesNo

If your child is required to take medication prescribed by a physician during the course of this event, and you wish PCS personnel to assist your child in taking this medication, please indicate by providing your full name below. In addition, please state the type of medication and provide a statement from the child's physician detailing the method, amount and time schedules by which such medication is to be taken.

In the case that I desire my child to apply sunscreen or insect repellant, I agree to supply said materials to PCS labeled with my child's name and application instructions. PCS camp personnel cannot apply these materials, but will supervise the application by the child.

Please send any Physician Statements to education@pcs.org.

Medication

Guardian/Parent full name

First NameLast Name

Note any other specific considerations regarding your child:

I grant authorization and consent for PCS to administer general first aid treatment for any minor injuries of illnesses experiences by the minor.

In case of serious accident or serious illness, I request PCS to contact me prior to rendering treatment to the patient. If PCS is unable to reach me, I hereby authorize PCS to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any medical diagnosis, treatment or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care but is given to provide authority and power to render care which medical or emergency personnel may deem advisable.

I agree to be financially responsible for any costs or expenses which are incurred in the above. I agree that any disclosure or use of any protected health information for my child pursuant to statements made or actions taken in accordance with this form shall not be violations of the federally protected rights under the HIPAA Privacy Rule, and I knowingly waive such privacy for these purposes.

I represent that I have legal custody of the above mentioned child.

In consideration of, and as part payment for, the rights for my child or children to
participate in activities with Portland Center Stage (“PCS”), including participation in
the PCS Teen Academy and events related thereto, including transportation to and
from, I have and do hereby voluntarily assume any and all risks of harm. I further
hereby release and discharge, covenant not to sue, and will indemnify and hold
harmless PCS, its officers, directors and employees, as well as its members,
managers, officers, subsidiaries, parent entities and trusts, affiliates, agents,
servants, and employees, and their respective successors heirs and assigns
(“Releases”), from any and all liability or causes of action or damages I now have or
that may arise directly or indirectly from or relate to participation in any of the
activities, including without limitation, liability or causes of action asserting or caused
by the negligence or breach of contract of Releases, and asserting loss of
consortium by or in relation to me, intending hereby to assume risks, grant a release
and to indemnify as broadly and inclusively and as unconditionally as permitted by
law.

The terms herby shall be binding on my heirs, executors and administrators. As a
parent or guardian, and, in consideration for permitting my minor child(ren) identified
below to participate in any of the activities of Portland Center Stage, the terms
hereof shall further serve as an assumption of risk and release for my child or
children. I personally agree to indemnify Releasees for any claims of such minor
child or children for any harm arising out of or relating to participation in the
activities, including claims asserting negligence of the Releasees. I also grant the
right to use any photos or films taken in their promotional effort.

Name of Minor*

Today's Date*

Date

Full name of Guardian or Parent*

Signature of Guardian or Parent*

Medical Information

Medication Assistance

Authorization and Consent of Legal Guardian(s)/Parent(s)

Release and Assumption of Risk Agreement