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Home
About Us
Location
Staff
FAQ
Registration
Productions
Past Productions
Videos
Box Office
Contact Us
Health and Emergency Form
Please also email a copy (front and back) of the student’s insurance card to lizamonjauze@mac.com.
Student Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Parent Email
*
Student Health Information
Does your child have any condition that would prevent him/her from participating in any program activities?
I authorize Liza Monjauze Productions (LMP) to administer ibuprofen and/or acetaminophen as needed for headaches or other minor aches and pains (unless negative indications for interaction with other prescribed medication per below).
Signature
Allergies (list all)
Carries Epinephrine for emergencies?
*
Yes
No
Carries inhaler for emergencies?
*
Yes
No
Dietary Restrictions
Has the student received any serious medical treatment during the past year that you would like to inform us of?
If so, include date and reason.
Does the student currently take medication?
*
Yes
No
If so, please list them.
If medication is to be given during the program, prescription drugs must be in original containers and program director must be notified.
Health Care
Insurance Provider
*
Policy Number
*
Doctor
*
First Name
Last Name
Doctor Phone Number
*
(###)
###
####
Any additional medical information?
Authorization to Consent to Treatment of a Minor in Case of Emergency, Illness, or Accident
Agreement
*
I, the undersigned parent of the student, do hereby authorize the directors of Liza Monjauze Productions as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but it is given to provide authority and power on the part of the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care, which the aforementioned physician or surgeon in the exercise of their best judgment may deem advisable. This authorization shall remain in effect until revoked in writing and delivered to said agents.
Signature
*
Thank you!
