PACIFICNORTHWESTBALLETSCHOOL

SUMMER COURSE 2016

Medical Information

Please complete and return to PNBS by June 1st.

Student name

last namefirst namemiddle initial

Birth date

Pacific NorthwestBalletSchoolmust receive this form before the student will be permitted to attend class.

Students must inform Pacific Northwest Ballet of any current injuries or serious injuries within the last year. Students who do not inform us of injuries may be asked to leave the Summer Course with no refund. In addition, note any physical conditions that might hinder the student from safely undertaking and maintaining the vigorous physical activity required for the Summer Course.

List and explain injuries and physical conditions:

Are there any other medical conditions Pacific NorthwestBalletSchool and/or the Dorm staff should be aware of? (For example, serious drug or other allergies, chronic diseases, etc.)

Signature of StudentSignature of Parent or Guardian

(If 18 years or older)(If student under 18 years old)

1.Health Insurance All students are required to carry their own insurance card.

□ I have enclosed a copy of my insurance Card

My health insurance policy number is

issued by

Name of Company

Address of Company

Check whether you are covered under _____ family or _____ individual policy.

Policyholder Name and Soc. Sec. #

Policyholder Birthdate:

Doctor’s Name: Phone:

If special form or pre-authorization is required, please be sure that the student and School have copies.

OVER
2. Medical Release

Person(s) to be notified in case of an emergency during the Summer Course (if student is under 18 years of age, please give name and address of parent or guardian).

Name Name

Relationship Relationship

Address Address

City, State, Zip City, State, Zip

Home Phone Home Phone

Work Phone Work Phone

Cell Phone Cell Phone

E-mail E-mail

If student is under 18 years of age, a parent or guardian must sign below. This signature is a requirement for your completed registration.

I understand that as parent or guardian of ,

Student name

I will be contacted in the event of a medical emergency and an administrator of Pacific NorthwestBalletSchool or appointed representative will sign for care only if I cannot be reached within a reasonable time. I hereby authorize medical care under those circumstances.

Signature of Parent or GuardianDate

3. Waiver of Liability

I agree that I will not hold the Pacific Northwest Ballet School, Pacific Northwest Ballet, or any faculty member or employee of either liable for injuries sustained or illnesses contracted while a student of the Pacific Northwest Ballet School Summer Course.

SIGNATURE OF STUDENTSIGNATURE OF PARENT OR GUARDIAN

(If 18 years or older)(If student under 18 years old)