Medical Release WaiverMUST be completed PRIOR to the start of Spring 2025 classes.Submit one (1) form for EACH student. Student Name * First Name Last Name Student Date of Birth * MM DD YYYY Does your student have any restrictions on activity? * YES NO If YES, please explain: Will your student need special assistance while in class? * YES NO If YES, please explain: Does your Child have any allergies? * YES NO Does your child carry an EpiPen? * YES NO If YES, please explain: Does your child have any dietary restrictions? * YES NO If YES, please explain: OTHER Please list any additional information the instructors should know. PARENT / GUARDIAN & EMERGENCY CONTACTS Parent / Guardian Name * First Name Last Name Parent / Guardian Phone * (###) ### #### Parent / Guardian Email * EMERGENCY CONTACT * List contact other than parent / guardian First Name Last Name Relationship to Student * Emergency Contact Phone * (###) ### #### MEDICAL RELEASE WAIVER* *By signing this waiver, I, the legal guardian of the student I have registered for Light House Center for the Arts, agree to the following conditions: I authorize Light House Center for the Arts to contact the persons named as parents or emergency contacts and to authorize the named physician to render such care for the student while he/she is enrolled in Light House Center for the Arts classes. Further, this signed statement certifies that my child is medically cleared to participate in the Light House Center for the Arts classes and to participate in all activities as described in the class descriptions while he/she is enrolled in class. Typing your name below confirms that you have read the medical waiver, that you understand it, and that you agree to be bound by it. * Full name of Parent / Guardian (listed above) that agrees to and adheres to this *Medical Release Waiver Thank you!Refresh this page to add another medical form.
