Consent for Medical Treatment

            In the event that I cannot be contacted through reasonable efforts, I, the undersigned parent/guardian/health care agent of  ____________________________(name and age), hereby empower and grant to the Stoughton Center for the Performing Arts, Inc. (namely Coleen Kehl) permission to consent to and authorize medical treatment for the individual named above.  This authorization shall be valid from September 1, 2009 thru August 31, 2010, at any function that I am not attending.  I do hereby indemnify and hold harmless the health care providers and entities and other persons who act in reliance upon this authorization.

            Executed this _______ day of _______________, 2010.

________________________

Print Name

________________________

Signature

Information:

Parent/Guardian/Health Care Agent can be located at the following address: __________________________________________

Phone number: _____________________________________

Name and Address of family doctor: _______________________________

Any known allergies/medical conditions: __________________________

_________________________________________________________________

Insurance Information:

Company____________________________________

Policy #:  ________________________________

Phone Number: ______________________________