MAD Camp Waiver & Liability Release Form Medical History and Student Insurance Information Insurance Company*: Plan ID/Group Number*: Insurance Policy Number*: Primary Physician*: Physician’s Phone Number*: Is the student taking any medications? Yes No If so, please list: Does the student have allergies? Yes No If so, please list: Please list any other medical conditions or special needs that we should be aware of, including any diagnoses of ADD, ADHD, autism or depression: PLEASE NOTE THAT WE CANNOT PROVIDE STUDENTS WITH ANY MEDICATION, NOT EVEN ASPIRIN. STUDENTS MUST PROVIDE THEIR OWN. In addition to the home, cell and work numbers you provided on the initial application, please provide any alternate phone numbers we should have in case we are unable to reach you at one of these numbers. This could be your spouse’s or partner’s cell or work, or the number of a nearby friend or relative. Other Emergency Contact Number*: Name/Relationship*: Liability Waiver and Model Release Statement I, the undersigned, waive and release any and all claims for myself and my heirs against Blue Bear School of Music, Young Performers Theater SF and Children’s Art Center, and any of their officers, directors, employees, agents or sponsors for any injuries or illnesses which may directly or indirectly result from participation in our classes. This waiver and release is valid from the date of my signature below, and shall remain effective unless and until modified in writing by the undersigned. I understand that Blue Bear, YPT and CAC may, from time to time, photograph student work in the classroom for marketing and archival purposes. In the event that a photographer comes to my class, I acknowledge that it is my responsibility to notify the photographer of my desire not to be photographed. I hereby grant Blue Bear School of Music, YPT and CAC permission to use photographs in which I appear for marketing, communications, and/or archival purposes. I waive any right to inspect or approve the finished product, including written copy that may be created in connection therewith. It is my understanding that such photographs will be copyrighted by the photographer and that no charge or special compensation is or will be required for my service/s. Name of Student*: A PARENT OR GUARDIAN MUST READ THE ABOVE AND SIGN THE FOLLOWING: By submitting this form online, I certify that I am the parent or guardian of the minor named above and have the legal authority to execute the above release and approve the foregoing. Name*: Date Submitted*:
