Center Stage
Dance Company Consent For Medical Treatment
As the parent or legal guardian, I hereby give consent to Center
Stage Dance Company and its employees to provide all emergency dental or medical
care prescribed by a duly licensed physician (MD) or dentist (DDS) for my child.
This care may be given under whatever conditions are necessary to preserve life,
limb or well being of my dependent.
_______________ _______________________________________________
Date
Parent/Guardian Signature
Does your child have any medical concerns or allergic reactions
of which we should be aware?
(Yes or No) _________
If yes, what?
_______________________________________________________________________________________
Physicians Name & Phone #
_______________________________________________________________________________________
Warning Agreement To Obey Instructions, Release,
Assumption of Risk, And Hold
Harmless
- I am aware that performing or practicing to perform/participate in dance
or dance related activities can be a dangerous activity involving
MANY RISKS OF INJURY.
I understand that the
dangers and risks of performing or practicing to perform/participate in
these activities include, but are not limited to, neck and spinal injuries,
injury to virtually all bones, joints, ligaments, muscles, tendons, and
other aspects of the muscular skeletal system, and injury or impairment to
other aspects of my body, general health and wellbeing.
- Because of the dangers of participating in dance or dance related
activities, I recognize the importance of following teachers’ instructions
regarding proper techniques, training and other class rules, etc., and to
obey such instructions.
- In consideration of Center Stage Dance Company for permitting me to
participate in dance or dance related activities, I hereby assume all risks
associated with participating and agree to hold Center Stage Dance Company,
its employees, agents, representatives, coaches, and all volunteers harmless
from any and all liability, actions, causes of actions, debts, claims, or
demands of any kind and nature whatsoever which may arise by or in
connection with my participation in any activities related to Center Stage
Dance Company. The terms hereof shall serve as a release and assumption of
risk for my heirs, estate, executor, administrator, assignees, and for all
members of my family.
I voluntarily sign my name evidencing my acceptance of the above
provisions,
and
further agree that no oral representations, statements or inducements apart from
this agreement have been made.
I have read this document. I understand that it is a release of
all claims.
1.
_____________________________________________________________________
___________________
Parent or Guardian (Signature/Relationship)
Date
2.
_____________________________________________________________________
___________________
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