Emergency Medical Authorization & Release Form
Guest student's first name *
Your answer
Guest student's last name *
Your answer
Guest student's age *
Your answer
Guest student's current grade
Your answer
I, _________________________ (parent or legal guardian), *
First and Last Name
Your answer
hereby give permission for my child, _________________________ (child’s name), *
First and last name of your child that will be attending Bring a Friend Week
Your answer
to participate in Bring a Friend Week with _________________________ (TDC Student's Name) at The Dance Centre By Heidi Glynias LLC (“TDC”), 1249 Smith Court, Rocky River, Ohio 44116, *
First and Last Name
Your answer
on _________________________ (date) *
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/
DD
/
YYYY
My child will be participating in the following classes: *
Your answer
Mother's Cell Phone *
Your answer
Father's Cell Phone
Your answer
Email address
Your answer
Other Phone
Your answer
Emergency Medical Authorization *
In the event my child requires medical care for any reason, I hereby authorize and give my consent to TDC and its employees, agents, and/or representatives to seek such care on behalf of my child and/or transfer my child to any hospital or medical facility at my sole cost and expense. If possible, TDC will make reasonable attempts to contact me at the phone number(s) listed above prior to seeking such care and treatment for my child.
Facts concerning child’s medical history, including allergies, medications, and physical limitations, etc.: *
Your answer
Release *
I recognize that there are risks of injury to my child or damage to personal property by participating in dance classes and related activities. I hereby release, discharge, and agree to hold TDC, as well as all of its employees, agents, and/or representatives, forever harmless for any personal injury or damage to personal property whatsoever that I or my child may suffer as a result of my visit to TDC, regardless of the cause thereof.
Participant’s Signature (age 18 or older)
By typing my first and last name below, I recognize this as my signature
Your answer
Parent’s Signature *
By typing my first and last name below, I recognize this as my signature
Your answer
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