Arkansas Thespian Festival

2018 — Paragould, AR/US

Health Form

 Health Form - Approval for Treatment



A health form MUST be completed by each student and adult attending Arkansas State Thespian Festival.



Last Name                                 First Name                     Delegates Birthdate


Troupe Director                                       Troupe #                                                High School       

Home address                                        City                                           Zip

Father/Guardian/Next of Kin Name                                                             Contact Number(s)



Mother/Guardian/Next of Kin Name                                                            Contact Number(s)


Allergic reactions to:


Medications presently taking:


Any past illnesses or other information that would be useful in the event medical treatment is necessary:






Circle One

Payment will be made by :      parent/guardian            student             insurance company


Family Physician

Health Insurance Company


Name of Insured


Policy Number


Group Number




Consent to Treatment

The undersigned hereby releases and agrees to hold harmless the Arkansas Thespians, Arkansas Educational Theatre Association, The International Thespian Society, The Educational Theatre Association, and all respective agents, employees and representatives of the aforementioned entities from any and all claims, demands, actions and causes of action as a result of the delegate listed above participating in the Arkansas Thespian festival 2016.  The undersigned further agrees to be responsible for him/herself while traveling to and from said Festival including any expenses incurred by the delegate and/or any personal injuries which may occur to the delegate.  The undersigned agrees to abide by the festival’s security rules and regulations with the understanding that should any problems occur with the delegate during the festival the delegate will be returned home and the parents, guardian, or next of kin of the delegate will be financially responsible for all necessary costs incurred.  The undersigned also realizes that festival registration fees cannot be refunded after january 22, 2016.  the undersigned further understands that should a major medical problem arise, he/she will be notified by telephone.  In the event that he/she cannot be reached, he/she gives consent to such medical treatment as deemed necessary, including x-ray examination and anesthesia to be rendered by a licensed physician or physicians.

The undersigned hereby grants Arkansas Thespians permission to make photographs/video recordings of the delegate at said  festival for use in coverage of the event, advertising,and for any lawful purpose without compensation to the delegate. The undersigned certifies that he/she has read and fully understands this authorization.



Signature of Parent/Guardian/Next of Kin                                                          Date