Fillable Broadway South Dance Studio Medical Release Form printable pdf download

Broadway South Dance Studio Medical Release Form

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Please return to Office Manager at time of registration

Broadway South Dance Studio Medical Release Form

I, _________________________________ (parent/guardian’s name), hereby give

permission for any and all medical attention to be administered to my child,

_________________________________ (child’s/children’s name(s)), in the event

of an accident, injury, sickness, etc. under the direction of the physician(s) listed

below or at any necessary emergency facility, until such time as I may be

contacted. I also assume the responsibility for the payment of any such treatment.

This release is effective at least to the end of the dance season following the

current season, but for not less than a period of one year from the date given

below.

Street address: _____________________________________________________

City: ________________________ State: ________ Zip Code: _____________

Home Phone: ______________________

Cell Phone: ____________________

Work Phone: ______________________

Insurance Company: ________________________________________________

Policy Number: _______________________________________

Child’s Physician: ___________________________________________________

Street address: _____________________________________________________

City: ________________________ State: ________ Zip Code: _____________

Physician’s Phone: ___________________________

Known Allergies & Existing Medical Conditions: _________________________

__________________________________________________________________

Emergency Contact Phone Numbers: __________________________________

Parent/Guardian Signature: __________________________________________

Date Signed: _________________

Broadway South Dance Studio Medical Release Form

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