Acda name honor choir medical permission form and liability waiver
High School Participant – Medical Permission Form and Liability Waiver
Santa Barbara, California – February 21-22, 2014
Required of all participants. Please print in blue or black ink.
Participant’s Name: ______________________________________ School: _______________________ (First)
Health Insurance Provider: Group ID/#:________________
(if no insurance, please write “none”)
Name of Policy Holder: _________________________________ Member ID/#: ________________
List all prescription medications you are currently or might be taking:Name: Dosage: Frequency: Reason:___________________Name: Dosage: Frequency: Reason:___________________Name: Dosage: Frequency: Reason:___________________
List any known food, drug, animal, or environmental allergies:
Circle any conditions for which the participant is currently receiving medical treatment:
List any other medical conditions for which the participant is being treated:
The designated Honor Choir Chair, Honor Choir Chair Assistant, and/or Honor Choir Coordinator, and the designated chaperone (if other than a parent) have my permission to administer (dual person observed and documented) the following to the participant if warranted:
(Circle) Tylenol Ibuprofen Imodium Dramamine Liquid Antacid Tums Other:_____________ If you wish to be called before any over the counter medication is dispensed, please initial here: If the participant listed above should require medical attention while participating in the Choral Leadership Academy in Santa Barbara, California, February 21-22, 2014, Merryl Nelson, CLA Personnel, and the designated chaperones have my permission to treat on site or take said participant to a doctor, hospital, or any other medical facility for necessary medical treatment, and I hereby authorize the release of medical information included on this document to the health care provider administering medical treatment to the participant. I hereby release, indemnify and hold harmless the American Choral Directors Association (ACDA), California Music Educator's Association (CMEA), Southern California Vocal Association (SCVA), their trustees, employees, volunteer workers, students, agents and assigns from any and all liability, damage, claim of any nature whatsoever arising out of or in any way related to my/my child’s participation in the Choral Leadership Academy in Santa Barbara, California.
Participating in any activity is an acceptance of some risk of injury. I agree that my/my child’s safety is primarily dependent upon taking proper care of oneself. Despite precautions, accidents and injuries may occur and injury and/or loss or damage to personal property may occur as a result of participating in the Choral Leadership Academy; therefore, I assume all risks related to participating in the Choral Leadership Academy in Santa Barbara, California. I also hereby acknowledge that ACDA, CMEA, SCVA, their trustees, employees, volunteer workers, students agents and assigns assume no liability whatsoever for personal injuries or property damage that may arise out of my/my child’s participation in the Choral Leadership Academy.
My signature on this form indicates that I have read, understood, and freely signed this agreement. I expressly agree that this agreement shall be construed and enforced in accordance with laws of the State of California. I agree that this waiver and release is intended to be as broad and inclusive as permitted under the laws of the State of California so that if any portion hereof is held invalid, the balance shall continue in full legal force and effect.
Signature: _______________________________________________ Completed original forms should be mailed to the following address BEFORE December 1, 2013:
Merryl NelsonCLA Coordinator1321 Pillsbury LaneEl Cajon, CA 92020
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