EMERGENCY MEDICAL RELEASE FORM

Name of Child ______________________________________________

Date of Birth ___________________________

Home Address __________________________ Phone __________________

Parents’ Business Phone _________________

Name and phone number to contact in case of an emergency ____________________
_____________________________________________________________________

I give my consent for the above named child to participate with the Extreme Ballroom Dance Company during the 2009-2010 year. I understand that there is a risk to any physical activity and will not hold Tim/Staci Huston or Extreme Ballroom Company, or any of their appointed teachers responsible for any injury my child/children may incur while participating with the Extreme Ballroom Company in the 2009-2010 year. I understand that at times, he/she will be traveling in vehicles with designated chaperones. I give my consent and authorization for my child/children to travel with designated chaperones to and from any specified activities. I also authorize the supervisors, or teachers to administer emergency or hospital treatment for any accident or illness and to act in my stead in providing any medical or dental care for my child/children.

Signature of parent or legal guardian ________________________ Date_____________

Insurance Information:

Company ______________________________________

Policy Number __________________________________

Group Number __________________________________

Medical Information:

Special diets Y N Allergies Y N Medication Y N

Chronic or recurring illness Y N

Surgery or a serious illness in the past year Y N

If you had to answer yes to any of the above, please give a full explanation of each in the rows below. If you need additional space, please use the back.