On the Stage
Liability Waiver & Medical
Release Form
Policies
I have read, and understood the Rhythm of my Heart, On the Stage policies. I accept and
agree to follow the policies. (Policies are located online at www.valeriedawn.com, under On the Stage Policies)
Child’s Name/Signature:
Parents/Guardian Signature:
Date:
Liability Waiver
I release Owner/Director,Valerie Dawn Cooper, Rhythm of my Heart, On the Stage, Garden Home Rec. Center and it’s staff, teachers, volunteers and management from any and all liabilities, claims and demands arising out of injuries incurred by my child while participating and/or performing in this activity, and performance team.
Child’s Name:
Parents/Guardian Signature:
Date:
Medical Release
I give my permission for Owner/Director, Valerie Cooper, Rhythm of my Heart, On the Stage to obtain any emergency medical treatment they deem necessary to my child’s well being. I give my permission for qualified, license, medical professionals to administer emergency medical treatment for any injury my child may incur. I understand owner/director Valerie Dawn Cooper, Rhythm of my Heart and the On the Stage does not assume responsibility for payment of a physician or hospital, in any situation.
Child’s Name:
Parents/Guardian Signature:
Date:
Emergency Phone Numbers:
Insurance Information:
Any medical problems/Allergies that I, or a medical professional would need to know about?