Fantasia Family Music Emergency Form

Please fill out the following form.

Child's Name

Child's Grade Level

Date of birth

Month

Day

Year

Parent 1 Name

Parent 2 Name

Parent 1 Email

Parent 1 Mobile Number

Parent 2 Email (Optional)

Parent 2 Mobile Number

Name and Telephone for Child's Physician

Name and Policy Number of Health Insurance

Does your child have allergies or dietary restrictions?

No

Yes

Does your child receive accommodations at school?

No

Yes

Does your child have any restrictions related to the musical theatre experiences that instructors should know? (For example, speech, sight, hearing, sensory or physical movement)

No

Yes

Is your child prescribed any medication of which we should be aware? (In case of an emergency situation)

No

Yes

If you answered yes to any of the questions above, please supply additional information. If no, please write N/A.

Name and Phone Numbers for at least 2 Emergency Contacts

Name and Phone Numbers of anyone who is permitted to pick-up your child

Initials

I hereby give permission for the student to engage in all program activities and agree to release Fantasia Family Music from all liability arising from any harm or injury incurred by my child in this program.

I give permission for Fantasia Family Music to use pictures or videos of my child in its marketing efforts.

Signature Acknowledging Above Information

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.