YA Medical Authorization Form

Young Artists Medical Authorization Form
Continuing Education + Community Outreach

Please complete all fields. All information is confidential and used only in the event of an emergency.

By completing this form you are agreeing to the following:

I consent to enter my child in the programs offered by the Cleveland Institute of Art. I agree to indemnify and hold harmless the Cleveland Institute of Art, its Board of Directors and all individual employees, administrators, teachers and volunteers from any claims, judgements and liability for any injury or loss due to my child’s participation in the programs.

1. Student's Name: *This question is required.

2. Emergency Contact Full Name: *This question is required.

3. Relationship to Student: *This question is required.

4. Preferred Contact Method: *This question is required.

5. Please enter at least one phone number where we can reach the listed emergency contact person:

Cell Phone #:
Home Phone #:
Work Phone #:

6. Granting Consent

I hereby give my consent that the following medical care providers and local hospitals be called in the event reasonable attempts to contact me have been unsuccessful. This consent is for (1) the administration of any treatment deemed necessary by a licensed physician and (2) the transfer of my child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concur in the necessity for such surgery is obtained prior to the performance of the surgery.
*This question is required.

7. If you do not give consent for emergency treatment/transfer of the student, please list alternative actions you'd like us to take:

7. Please list any known student allergies (N/A if none): *This question is required.

8. List all facts concerning the student’s medical history, including allergies, medications being taken, and physical impairments to which any physician should be alerted (N/A if none):
*This question is required.