Allergic reactions to:

None

Medications presently taking:

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

Family Physician

Health Insurance Company

Name

Name of Insured

Phone

Policy Number

Address

Group Number

Address

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.