Theatre Emergency Form

On September 10, 2011, in Uncategorized, by Dorothy Dunnion

BROPHY COLLEGE PREPARATORY

 

ALL MUST COMPLETE AND HAVE SIGNED REGARDLESS OF AGE!

 

PERMISSION
TO PARTICIPATE IN BROPHY COLLEGE PREPARATORY THEATRE

AND

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

                                _________________________________________________________________________________

 

 

 

____________________________________________________________________ ___________________________________

            (Name of Student – Please Print)                                                      (Birth
date)

 

 

 

____________________________________________________________________ ___________________________________

(Home Address)                                                                                 (Telephone)

 

 

The above-named
student has the unqualified permission of each of the undersigned to fully
participate in BCP  Theatre.

 

The above-named student may travel by means of    VANS
BUS       CARPOOL
(circle one)    or by any other means deemed
appropriate by BROPHY COLLEGE PREPARATORY.
Each of the undersigned hereby authorizes BROPHY COLLEGE PREPARATORY to
allow the student to travel to, and to fully participate in, such school
activities.  Each of the undersigned
further agrees to hold Brophy College Preparatory harmless for any injury or
damage arising out of said student’s travel to or participation in such school
activities.

 

In the event
of a medical emergency, the undersigned parent/guardian of the above-named
student hereby grants authorization to BROPHY COLLEGE PREPARATORY, and to its
teachers, coaches, agents and other representatives, to employ any legally
licensed physician or health care facility on behalf of each of the
undersigned, and to direct and/or order emergency medical treatment for the
above-named student.  Each of the
undersigned further agree that neither BROPHY COLLEGE PREPARATORY, nor its
teacher, coaches, agents or other representatives, shall be liable under any
circumstance to any of them for exercising the foregoing authority in the event
of an emergency.

 

 


_____________________________________________________                        _________________________

(Signature of Student)                                                                                                (Date)

 

 

 


_____________________________________________________                        _________________________

(Signature of Parent/Guardian)                                                                                 (Date)

 

 

 


_____________________________________________________                        _________________________

(Signature of Parent/Guardian)                                                                                 (Date)

 

 

 

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