Medical Release Form 2024
Hello! We are so excited to have you and yours! Please make sure to complete thoroughly and accurately :) This form must be completed by a parent or guardian unless the participant is over the age of 18.
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Email *
Participant Name *
Parent/Guardian(s) Name *
Person Completing the Form
Parent Guardian Work/Daytime Phone *
Emergency Contact Name *
Emergency Contact Phone Number *
Participant's Insurance Company *
Participant's Physician's Name *
Participant's Physician's Phone Number *
Relevant Medical Information: Please list any conditions we should be aware of, such as asthma, allergy to bee stings or food, anxiety, notable recent events-including emotional or behavioral, current medications or difficulties. If you're not sure if it's relevant, please let us know! We want to support you or your participant's physical and mental health in any way we can.
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I give my permission for my child to participate in the 2021 Shakespeare Program in Chelsea, Vermont. I understand that all physical activity involves some risks. I assume all risks associated with participation in this program, including but not limited to, falls, contact with other participants, working barefoot, the effects of weather, traffic, COVID-19, and other reasonable risk conditions associated with the program. All such risks to my child are known and appreciated by me. I understand this informed consent form and agree to its conditions on behalf of my child. Further, I authorize the program staff to seek emergency medical treatment of any injury or illness my child may experience. If qualified medical personnel consider treatment necessary, they may perform the treatment. This authorization is granted only if I cannot be reached and a reasonable effort has been made to do so, or in a life-threatening situation. 
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