EMERGENCY INFORMATION


Emergency Contact's Name:


Relationship:


Mobile Number:




Informed Consent and Acknowledgement: I approve my child’s participation in
the activities of The Cicely Tyson Theatre Workshop at St. Philips Episcopal
Church during the selected class period. In exchange for accepting my child’s
participation, I assume all risks and hazards incidental to the conduct of its
activities and release, absolve, and hold harmless all its respective instructors
and representatives from any liability for injuries to my child arising out of
dramatic improvisation, creative exploration, or traveling to, participating in, or
returning from selected field trips. (We will always provide class supervision and
chaperones for field trips.)

Medical Release and Authorization
As Parent or Guardian of the named student, I hereby authorize the diagnosis
and treatment by a qualified and licensed medical professional of the minor child
in the event of a medical emergency, which, in the opinion of the attending
medical professional, requires immediate attention.

Confirmation: I ACKNOWLEDGE AND AGREE TO THE ABOVE BY SIGNING
BELOW



Parent/Guardian Signature: