Name *
Name
Insurance company phone *
Insurance company phone
Doctor's phone *
Doctor's phone
Person(s) to be notified in case of an emergency during Vivace! Chamber Players. If student is under 18 years of age, please give name and number of parent or guardian.
Emergency Phone 1 *
Emergency Phone 1
Person(s) to be notified in case of an emergency during Vivace! Chamber Players. If student is under 18 years of age, please give name and number of parent or guardian.
Emergency Phone 2
Emergency Phone 2
I understand that as a parent or guardian of the student listed below, I will be contacted in the event of a medical emergency and an appointed representative will sign for care only if I cannot be reached within a reasonable time.
I hereby authorize medical care under the circumstances listed above. *
WAIVER OF LIABILITY *
I agree that I will not hold Vivace! Chamber Players or University Prep or any faculty member of Vivace! Chamber Players liable for injuries sustained or illnesses contracted while my child participates in Vivace! Chamber Players.