978-465-0840
home
schedule
productions
auditions
registration form
medical form
faq
workshops
about us
contact us

medical form

Please fill out the form below:

Student's First Name:
Student's Last Name:
Date of Birth:
E-Mail:


Class Requested:


Allergies (including insect stings)
 
Check All that apply:
Asthma Heart Disease Diabetes
Hearing Impairment Convulsions Seizures
Epilepsy Sight Impairment
Frequent Headaches or Ear Infections
Other:
 
Operations
 
Regularly Taken Medications:
 
Are there any restrictions and/or instructions relating to the student's participation in Drama programs? If yes, please list:


By submitting this form, I certify that the medical information given above is accurate. If any limitations exist or arise that prevent her/his participation in Drama Workshop programs, I will notify the staff immediately. Removal from participating in the program may be required until such time that corrective action is taken to allow the child to resume participation. A doctor's note stating the cild may resume "VIGOROUS PHYSICAL ACTIVITY" is required before student is allowed back to classes.
 
Name:
Relationship to Child:


INSURANCE INFORMATION AND RELEASE
FOR EMERGENCY MEDICAL TREATMENT
Name of Insurance Company Child is Covered By:
 
Address:
City:
State:
Zip:
Policy Number:
Policy Holder Name:
Relationship to Child:


My child does not have insurance coverage


Submission of this form certifies that as the child's parent or legal guardian, I/we hereby give our consent to the teachers and staff of the Drama Workshop to administer emergency CPR and First Aid by certified personnel and obtain medical care from any licensed physician, hospital, or clinic for any injury that may arise.


Comments:


THIS FORM SHOULD BE UPDATED ANNUALLY. PLEASE NOTIFY THE STUDIO IF ANY OF THIS INFORMATION CHANGES.