Please list ALL medical conditions – physical, emotional, and mental - that we should be aware of - any limitations present that would require additional considerations to enable the student to participate
Please list ALL medications taken routinely by student
Please list any food allergies/medication allergies/other allergies
The person herein named has permission to engage in all dance classes and rehearsals unless otherwise noted.
I hereby give permission to the Moving Arts Exchange (MAX) to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for me/my child, as may be necessary, including, but not limited to x-rays, routine tests and treatments, and/or hospitalization. I also give permission for MAX to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes.
It is my intention that MAX be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of MAX be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR & 164.510(b)) to the disclosure to the MAX representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to the MAX representatives related to the person’s ability to participate in music, theatre, and dance classes, rehearsals, and performances; and (ii) in the case of minors, to provide relevant information to the MAX representatives to keep me informed of my child’s health status.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by MAX to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips off-site.