Print this off and bring completed form to Peoria Ballet.
Form Must Be Notarized
MEDICAL INFORMATION
Student Name: _________________________________________________________
Age: __________ Birthdate: _____________________________ Sex:________
Address: ______________________________________________________________________
Day Phone: __________________________Evening Phone: ______________________________
cell:___________________ cell:__________________________ cell:________________________
Physician: __________________________________________Phone: ______________________
Physician’s Address:______________________________________________________________
General Health: Excellent_______ Good_______ Fair_______ Poor_______
Significant Family History:___________________________________________________________
_______________________________________________________________________________
Known Allergies (including drug and environment): _____________________________________
______________________________________________________________________________
Medication the student is currently taking (including vitamins, minerals, or other dietary herbal supplements):___________________________________________________________________
_______________________________________________________________________________
Chronic Illnesses or Pre-Existing Conditions: ___________________________________________
_______________________________________________________________________________
Student’s Blood Type: ______________
Has the student had any of the following conditions? Check ALL applicable boxes and specify dates.
Chicken Pox: _______________ Eating Disorder: _______________
Mumps: _______________ Rheumatic Fever: _______________
Measles: _______________ Ear Infections: _______________
Rubella: _______________ Vision Difficulties: _______________
Tuberculosis: _______________ Sickle Cell Trait: _______________
Seizures: _______________ Circulatory Problems: __________
Lyme Disease: _______________ Anemia: _______________
Diabetes: _______________ Dizziness/Blackouts: _______________
Hypoglycemia: _______________ Fatigue: _______________
Epilepsy: _______________
Serious Illness: _______________ Please Explain: _______________
______________________________________________________________
INJURIES: _____________________________________________________
______________________________________________________________
*****NOTE: If you have a chronic condition or a current medical problem, please bring a signed statement from your physician permitting class and/or performance participation.
Is the student receiving psychological or psychiatric counseling? ___________________
Is there anything else in particular you would like us to know about the student? ________
______________________________________________________________________________
_______________________________________________________________________________
INSURANCE INFORMATION
Insurance Company: ____________________________________ Policy Number: __________________
Name of Policy Holder (PH): _____________________ PH’s Profession: __________________________
Policy Holder’s Employer: __________________ Address:______________________________________
PH’s Social Security Number: ________________________ Students SS#: ______________________
In Case of Emergency, Please Contact (other than parents):
Name:__________________________________________________________________________________
Relation to Student: ____________________________________________________________________
Work Phone: ____________________________ Home Phone: ________________________________
Family Physician: __________________________________________ Phone:_____________________
Waiver and Claim and Release of Liability
The undersigned, by signing this waiver of claim and release of liability acknowledges that there are certain inherent risks associated with dance, any of which could result in property damage or bodily injury. These risks include, but are not limited to: warm-up, class, rehearsal, performance, or transport of artists.
In consideration for the consent and right given to the undersigned to dance with the Peoria Ballet, and with full understanding of the inherent risks involved, the undersigned does/do, by signing below, expressly assume all risks of any nature whatsoever and does/do hereby release and forever discharge the Peoria Ballet, their officers, directors, shareholders, employees and agents, from any claim or liability of property or bodily injury and any nature whatsoever arising out of the Peoria Ballet operation, and the undersigned does/do acknowledge full and total personal insurance responsibility while participating with the Peoria Ballet.
Dated this ____________ day of ____________________, 20____
Participant’s Signature_________________________________________________________________
Parent or Legal Guardian’s Signature (if participant is under 18)
________________________________________________________________________________________
CONSENT TO MEDICAL TREATMENT
In the event of an emergency, when parental permission is not available, I hereby give my permission for a staff member of Peoria Ballet to consent to medical treatment for (name of student)
_______________________________________________________________________________.
Signature of Parent or Legal Guardian (Student if over 18) ________________________________
Date: ___/___/___ Sworn to and subscribe before me this the _____ Day of ___________, 20__
County of ________________________, State of ______
Notary Public __________________________________________________________________________
My commission expires: _____________________________