Permission | Health Form

Art Castle Dance Academy Permission|Health

This form must be completed and on file for you or your child to participate.
Dancer's Name*

First NameLast Name
Age*
If over 30 you can put your favorite age :)
Address*

Street Address

Street Address Line 2

City, State ZipState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Your Name*

First NameLast Name
Cell Number*
Work Number
E-mail*
example@example.com
I can most easily be reached:*

By PhoneBy TextBy E-mail
Emergency/Medical Information
If you are not reachable, what is name of another adult to whom the student may be released/who may be contacted in case of emergency:
Emergency Contact's Name*

First NameLast Name
Relationship*
Cell Phone Number*
Alt. Phone Number
Others authorized to pick up student- please list name and relationship:
So that we may better assist you/your child and also in case of emergency, please list allergies, dietary restrictions, medical conditions, medications being taken, physical impairments and/or special needs:
EPI-PENS, INSULIN KITS & INHALERS If students typically keep these medications with them at school, then students should keep these medications with them while in class.
In the event that a medical history needs to be obtained, the following are my/my child’s usual caregivers:
Primary Care Doctor:
Name and Phone
Dentist:
Name and Phone
Please list any other information you think we should know regarding your child:
Emergency Medical Authorization:
In the event reasonable attempts to contact me or another authorized person listed above have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary and/or the transfer of myself/my child to any hospital reasonably accessible.
Emergency Medical Authorization*
Participant Waiver

By registering you grant permission for the The Arts Castle to use photographs and/or videos of you or your child in publications, marketing materials, website, social media and in other communications related to the mission of The Arts Castle.

Also, I release and discharge the Delaware County Cultural Arts Center (The Arts Castle), their agents and employees for any damages, actions, demands and injuries arising out of any participation in this activity, whether they arise at The Arts Castle, out of travel between The Arts Castle and any off-site location, or at any offsite location while participating in the program. I have full knowledge of all risks involved in my/my child’s participation in the class.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT and WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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Date*

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Art Castle Dance Academy Permission|Health