Pennsylvania Youth Theatre School of Performing Arts
2006-2007 Medical / Photo Consent

IN ORDER TO SECURE A STUDENT’S PLACEMENT IN A CLASS, THIS FORM MUST BE SIGNED BY A PARENT/GUARDIAN AND RETURNED TO THE MAIN OFFICE.

EMERGENCY CONTACT    (IN THE EVENT WE ARE UNABLE TO A REACH PARENT):

Name: ______________________________________________________________

Phone: _____________________________________________________________

Family Physician: ____________________________________________________

Phone:______________________________________________________________

Address: ____________________________________________________________


Please tell us, in confidence, of any medical condition(s) your child has that we should be aware of (i.e., allergies--especially food allergies--medications, disabilities, etc.):

___________________________________________________________________________________________

Medical Insurance Policy Number:_____________________________________

MEDICAL AUTHORIZATION
I hereby authorize, consent and direct the Pennsylvania Youth Theatre, its directors, officers, and employees, and any physician, hospital, or other health care provider selected by the Pennsylvania Youth Theatre, to take such action as is necessary in the circumstances to provide emergency care and related treatment to my above-named child in my absence, should the need arise while he/she is participating in the programs of the Pennsylvania Youth Theatre. I hereby designate the Pennsylvania Youth Theatre, its directors, officers, and employees as my authorized agent for the signing of any consent forms required by any such health care provider in connection with such health care.

The undersigned has received, read and agrees to the stated Policies and Procedures of PYT

Date:_______________________

Signature of Parent/Guardian:_____________________________________________

PHOTO RELEASE
o YES - I give permission for PYT to use any picture, electronic image and/or audio/video recording of my child for promotional purposes.

VOLUNTEERS
Parents are strongly encouraged to volunteer as class parents.  PYT offers a number of opportunities for parents to get involved. Some duties include: providing holiday snacks for Halloween and Valentine’s Day; assisting the office with phone calls, if needed; and helping out with the end-of-year showcase, PYT Performs!

o YES I would like to volunteer as a class parent.