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Illinois Medical Release Form 2

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This form is provided for the medical and liability release regarding the necessary medical care and treatment to be administered to people participating the 2012 Illinois High School Theatre Festival.

Illinois Medical Release Form 2
Illinois Medical Release Form 2
MEDICAL/LIABILITY RELEASE FORM
2012 Illinois High School Theatre Festival
Return this form to your instructor.
Each participant, including all adults, must complete a medical release form. Please type or print legibly.
All forms and payment must be received before registration is considered complete.
Participant Name _________________________________________________________ Date of Birth _______________________________________ Age ____________________
Home Address ___________________________________________________________ City ___________________________________ Zip _______________________________
Home Phone ____________________________________________________________ Cell Phone __________________________________________________________________
Parent/Guardian First and Last Name ______________________________________________________________________________________________________________________
School Name ____________________________________________________________ Primary Sponsor _____________________________________________________________
School Address __________________________________________________________ City ________________________________ Zip _________________________________
School Phone ____________________________________________________________ Fax ________________________________________________________________________
In case of emergency, contact ___________________________________________________________________________________________________________________________
Contact Home Phone _____________________________________________________ Contact Work Phone _________________________________________________________
Do you have insurance
Yes (if yes, please indicate policy below)
No
Health Insurance Company ______________________________________________________________________________________________________________________________
Policy # ______________________________________________________________________________________________________________________________________________
Allergic to any medications ____________________________________________________________________________________________________________________________
SIGNATURES: Participant refers to the student, chaperone, or sponsor who is attending Festival (participants must sign on line
A). Parent, guardian, or next of kin must sign on line B. NOTE: All students participating, even if over the age of 18, must
have a parent, guardian, or next of kin’s signed permission. Please read the following carefully!
1. The undersigned participant (student, chaperone, or sponsor) agrees to abide by Festival rules and regulations. The undersigned
sponsor/parent/guardian/next of kin agrees to be responsible for the above named people while traveling to and from Festival including
any expenses incurred by the above named participant, caused by the above named participant, and/or any personal injuries which may
occur to the above named participant.
2. I understand that in case of serious injury, I hereby give my permission for emergency medical treatment, as recommended by
a physician; I understand that no surgical procedure will be performed without my permission and consent; I understand that
any medical expenses are my nancial responsibility.
3. I hereby release, acquit, and forever discharge the Illinois Theatre Association, Illinois State University, its Board of Trustees, employees,
agents, and representatives, from any and all claims, causes of action, damages, or judgments, whether in contract or in tort, for any
injuries including personal that may be incurred arising out of or in any way connected to the attendees participation (signature and
date required for participation).
A __________________________________________________________________________________________________ Date ________________________________________
Signature of Participant (student, chaperone, or sponsor)
B __________________________________________________________________________________________________ Date ________________________________________
Signature of Parent, Guardian, or Next of Kin
Please Note that Prior Years Forms Will Not Be Accepted.
Illinois Medical Release Form 2