Avant Dance

6300 SPID #21

Corpus Christi, TX  78412

(361) 653-3269

 

RELEASE AND INDEMNITY /

EMERGENCY MEDICAL RELEASE AUTHORIZATION

 

Required insurance information, medical authorization, and indemnity/emergency medical release form to be filled out by all participants.

 

COMPLETE & RETURN TO AVANT DANCE BY __________________________

 

Name of Dancer: ____________________________________________________

Insurance Company: _________________________________________________

Policy #/Group #: ____________________________________________________

Name of policy holder/Insured: _________________________________________

 

I hereby give my permission for the director, teacher, or chaperone(s) of Avant Dance to authorize any emergency medical treatment that may be required by the above named participant during the                                                                                                        (competition)on                                                         (dates).  I understand I am responsible for any and all charges as a result of such care or medical treatment.

 

I release and hold harmless Avant Dance and any chaperones or drivers  to, from, or during the competition for any and all liabilities while the above-named participant is traveling to or from, attending any and all events and activities, and performing at the

                                                                               (competition). It is warranted and represented that the indemnities contained herein shall be continuing in nature, and shall cover any conditions which may arise in the future and which directly or indirectly arise from the matters specified herein.

 

Parent or Guardian Signature:  __________________________________________

Parent or Guardian Name (Please Print) _________ _________________________

Date ____________________         Social Security #_________________________

Home Ph # ____________Cell Ph # ______________ Work Ph #_______________

 

Insured’s Signature  ___________________________________________________

Insured’s Name (Please Print)  __________________________________________

Date_________________    Social Security #  ______________________________

Home Ph # ____________Cell Ph # ______________ Work Ph #_______________