Medical Treatment form for Mamma Mia
This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible for parents to be present on the scene.  

I do hereby state that Tecumseh Youth Theatre has my consent to summon any and all professional emergency personnel to attend, transport and treat the minor child stated below, and issue consent for treatment and hospital care by licensed professionals until a parent or legal guardian can become available.  I agree to assume financial responsibility for expenses of such care.

It is understood that this authorization is given in advance of such medical treatment, but is given to provide authority and power on the part of Tecumseh Youth Theatre to exercise his or her best judgement upon the advice of any such licensed physician, surgeon and or hospital.

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Parent #1 Full Name *
Parent #1 Emergency Contact Phone Number *
Parent #2 Full Name
Parent #2 Emergency Contact Phone Number
Student Full Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Student Gender *
Physician Information - Name of practice and contact phone number
Medical Plan coverage information - Carrier, policy number
Any conditions, allergies or significant medical information that would effect treatment
If no parent can be listed above - Emergency contact #1
Emergency Contact #1 Phone Number
If no parent can be listed above - Emergency contact #2
Emergency Contact #2 Phone Number
Parent Electronic Signature *
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