2018 PROgressions Medical Release Form

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2018 PROgressions Medical Release Form

2020 PROgressions MEDICAL RELEASE FORM

Dancer's FULL Name (first, middle and last) *
Dancer Age (as of event) *
Dancer Birthdate *
List Any Dancer Allergies
List All Medications Currently Being Taken
List Anything Else Medically Related About Dancer We Should Be Aware Of
Health Insurance Company Name *
Policy No. *
Primary Care Physician Name and Phone No. (with area code) *
INCLUDE THE FOLLOWING INFORMATION FOR EACH EMERGENCY CONTACT LISTED BELOW:
NAME, CELL PHONE NO. (with area code), RELATIONSHIP TO DANCER
Emergency Contact 1 *
Emergency Contact 2 *
Emergency Contact 3
SUBMISSION OF THIS FORM CONSTITUTES APPROVAL OF THE FOLLOWING: As the parent, legal guardian or authorized legal agent for the above named dancer, I grant Talent On Parade, LLC and its staff the right and authority to make emergency medical decisions in good faith, and in the best interest of my child for the period of the PROgressions program dates: July 26-29, 2020.
Electronic Signature *Typing your name into this form, and then submitting this form to Talent on Parade, LLC. via https://talentonparade.com, is for all intents and purposes, to be considered a valid and legally binding signature.
Date *
Parent/Guardian Name *(first and last)
Parent/Guardian Cell Phone No. (with area code) *
NEED HELP? Contact the TOP office at (316) 522-4836 with any questions or for assistance in completing/submitting this form.

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