EMERGENCY CONSENT, ACKNOWLEDGMENTS OF RISK, PERMISSION, and AUTHORIZATION FOR MEDICAL CARE FORM
Name of student: _____________________________________ Age: __________
Doctor’s name: _________________________________ Phone: _________________
Doctor’s address: ________________________________________________________
Allergies/reactions: _____________________________________________________
Medications: ____________________________________________________________
Date of last Tetanus shot: __________________ Other shots current? ___________
Insurance Company Name: ______________________________________________
Insurance Company Address: ____________________________________________
In case of emergency, my child should be taken to __________________________.
(Please list the medical facility to which you desire your child be taken.)
ACKNOWLEDGEMENT OF WARNING, and RELEASE OF LIABILITY AND HOLD HARMLESS
As the parent(s) or legal guardian(s) of ________________________, I/we hereby release and agree to defend and hold harmless Portland Public Schools from any claims from any person, entity, in any forum that may arise against them by reason of property loss or damage, injury and/or death resulting from any cause including but not limited to, the student or other participant’s having failed to properly carry out instructions from the Group Leadership, but EXCEPTING those which occur because the Leadership negligently failed to take reasonable steps available to it to protect the student from an immediate substantial hazard actually known to the Leadership.
I/we hereby acknowledge that the activity may contain inherent risks of possible bodily injury. By signing below, I hereby give permission to any staff member of Portland Public Schools to seek and consent to medical and/or dental attention, care, or operation for my child only in an emergency. No child shall be allowed to participate in this optional activity until this form is signed and dated by the participant and the parent/guardian.
By signing below, it is with my full consent that _______________________ will attend the Theatre Arts Program during school, after school, and/or during the summer for Roosevelt High School Campus, Thespian Troupe #7289, and Opening Act Theatre Company.
Parent signature: _____________________
Date: ____________
Student signature: ___________________
Date: ____________
PROGRAM GUIDELINES FORM
All participants have a responsibility to themselves and one another to maintain the highest standards of conduct at all times. Because we care about the safety of each participant, the following guidelines have been developed:
1. The theatre will be used only during approved hours of operation.
2. All participants are to remain at the site or other pre-approved space with an adult present at all times, unless previously authorized to leave. Caution will be exercised with respect to the neighborhood. Stay with at least two other people when outside.
3. All participants must have a signed permission, medical, consent, and risk form on file in order to attend.
4. Arrival on time by 8:45 A.M. and full participation is expected from both participants and adults. Departure on time daily as the building is closed and alarmed by 4:00 P.M. (except the last Friday when students stay through the end of the evening show.)
5. Possession or use of alcohol or drugs is strictly prohibited and will result in an automatic trip home at the expense of the participant as well as disciplinary action.
6. No inappropriate sexual acts, thank you.
7. Respect for company members and all those with whom we may come into contact is essential both in action and regard to personal property.
8. All property of OATC and site will be cared for and respected. Members are responsible for keeping the property clean and in good condition. Any damage of property is the responsibility of the participant and cost for repairs will be charged to the individual(s) involved.
I understand the guidelines that have been set for Opening Act Theatre Company and agree to abide by the rules. I understand that any violation of these guidelines will warrant a review by the adults and may result in a loss of privileges or being asked to leave permanently without reimbursement.
Parent signature: _____________________
Date: ____________
Student signature: ___________________
Date: ____________
MEDIA PERMISSION FORM
I understand that Opening Act Theatre Company may use my child’s image, quote, or likeness in future brochures or promotions for Opening Act Theatre Company without addition notification.
Parent signature: _____________________
Date: ____________
Student signature: ___________________
Date: ____________
