Release Authorization & Medical Form
Student name:
Parent/Guardian Name:
Email address:
Cell:
Mailing address:
Request information on:
Date: Medical History: Allergies, physical limitations & special considerations:
	Health and Medical Waiver   The parent/legal guardian warrants that their child is physically fit and able to participate in all FAME activities, and consents to any employee, agent, or other person affiliated with Fine Arts Music Programs to seek medical attention and treatment or other measures deemed necessary or advisable for the above-named child in the event of an accident, sudden illness, or other condition that occurs while the above-named child is in the care or under the supervision of Fine Arts Music Programs Personnel.   The parent/legal guardian signing this form releases Fine Arts Music Programs personnel from any liability for such decisions or actions in seeking medical care, and agrees to pay all the costs and fees for the medical care or treatment authorized under this emergency medical authorization. Parent/Guardian Signature  * required