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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.
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:
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.