Release of Liability We understand that Cadence Theatre Company (CTC) and Virginia Repertory Theatre employees take many precautions in the supervision of students in their care. We agree to indemnify and hold harmless Cadence Theatre Company and Virginia Repertory Theatre, their agents, officers and/or employees from all claims, damages, injuries, or other liabilities of any kind whatsoever that could be brought now or in the future by the enrollee arising from any action or inaction by Cadence Theatre Company and Virginia Repertory Theatre, their agents, officers and/or employees, recognizing that certain reasonable risks exist in any theatre arts activity. Further, I grant Cadence Theatre Company and Virginia Repertory Theatre, its agents and employees permission to authorize any emergency medical treatment that may be required for me during the 2014-2015 season. My medical insurance carrier is: ______Insurance Company Policy Number/Group Number: ______
Cover Dates: ______
Signature of Student (or Parent/Guardian):______
Date: ______
Medical Information:
Is the student allergic to anything (medication or other)?
If YES, please list: NO/YES______
Does the student take any medication on a regular basis?
If YES, please list: NO/YES______
Are there any medical conditions we should be aware of?
If YES, please list: NO/YES______
Primary Care Physician’s Name: ______P a g e | 2 Phone #: (______) ______Emergency Contacts:
If you would like to provide contacts in case of emergency, please do so below:
Name: ______Phone #: (______) ______
Relation: ______
Name: ______Phone #: (______) ______
Relation: ______
I, the undersigned, have read this release/authorization and understand all of its terms. I execute it voluntarily and with knowledge of its significance. I have executed this release/authorization on the day and year stated above.
Student’s Name: ______
Signature of Student: ______Date: ______Signature of Parent or Guardian (if applicable):______
Permission to Use Photo Cadence Theatre Company and Virginia Repertory Theatre have permission to use my photo (or child’s photo) in the creation of materials used to publicize their programs. We understand that CTC and Virginia Repertory Theatre do not publish the full names of minors. This permission is granted for all photos taken during the 2013-2014 season. Name: ______Child’s Name (if applicable): ______Signature of Student: ______Date: ______Signature of Parent/Guardian (if applicable):______Date:______