Warren Central Performing Arts Department - Permission Slip and Health Form
This permission slip is used to authorize your student to participate as part of the Warren Central Performing Arts Programs.
School authorities, parent chaperones, and staff may need to use the medical information provided.
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Email *
Student Last Name *
Student First Name *
What Performing Arts Ensemble are you in? *
If you are in both Connection and Chamber Singers, please choose Connection.
Required
Student Street Address *
City *
Zip Code *
Home Phone (Area Code) XXX-XXXX Format *
Secondary Phone (Area Code) XXX-XXXX Format *
Student Email Address - IMPORTANT *
Parent Email Address #1 - IMPORTANT *
Parent Email Address #2 (optional)
List any allergies *
Does your child have any health conditions that may limit their participation in any activities? If so, explain. *
List any medications your child is taking *
List any medications your child may NOT take *
May the chaperones/staff provide the following to your child on request? *
Yes
No
Asprin
Acetaminophen/Tylenol
Midol
Ibuprofen/Motrin
Pepto Bismol
Saline Solution
Throat Lozenges
Aleve
Peroxide
Cough Suppressant
Sudafed
Calergy Lotion
Bee Sting Relief
Sunscreen
Eyedrops
Benedryl
Date of last tetanus immunization. (month/year) *
Does your child wear contact lenses and/or removable dental appliance? *
Parent/ Guardian First Name *
Parent/ Guardian Last Name *
Parent/ Guardian Phone (Area Code) XXX-XXXX Format *
Parent/ Guardian Work Phone (Area Code) XXX-XXXX Format *
Parent/ Guardian Other Phone (Area Code) XXX-XXXX Format
Name of a responsible adult to contact in the event a parent/ guardian cannot be reaching. (First & Last Name - Including Relationship) *
Responsible Adult's Phone (Area Code) XXX-XXXX Format *
Student's Physician Name *
Physician Office Phone *
Insurance Company *
Insurance Phone Number (Area Code) XXX-XXXX Format *
Insurance Address *
Insurance Policy/Group # *
Name of Insured (as displayed on identification card) *
I hereby grant permission for my child (named herein) to participate in all rehearsals, travel, trips, and activities (involving some water related activities) with the M.S.D. of Warren Township, Warren Central Performing Arts Department, and Warren Performing Arts Association. I understand that this activity does expose my child to the risk of injury or death. I further understand that participation in these trips will involve activities off of school property and that neither the M.S.D. of Warren Township nor its employees will have any responsibility for the condition of non-school property. Furthermore, if immediate observation or treatment is urgent in the judgment of school authorities, I authorize and direct the school authorities to send my child, properly accompanied, to the hospital, doctor, or dentist most accessible. I further agree to reimburse the M.S.D. of Warren Township and/or Warren Performing Arts Association for any medical expenses that may be incurred by my child while they are participating in these activities. By providing your name (Parent/Guardian) below you agree to the following statement: This Agreement may be executed by facsimile, portable document format (.pdf) or similar technology signature, and such signature shall constitute an original for all purposes. Please type your First and Last Name - Parent/ Guardian ONLY. *
Parent/ Guardian's First & Last Name - ONLY
Executed on this date: *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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