Marsh Youth Theater Emergency Record

Student's Name __________________________ Date of Birth ____________________________
School __________________________ Grade ____________________________
Contact Parent/
Guardian name 		_________________________________________________________
Home Address __________________________ City, State ________________ ZIP ________________
Phone (home) __________________________ WORK / CELL ________________ e-mail ________________
Other Parent/
Guardian name 		_________________________________________________________
Home Address
(if different from above)		 __________________________ City, State ________________ ZIP ________________
Phone (home) __________________________ WORK / CELL ________________ e-mail ________________
Local Physician's Name ______________________________ Office Phone ______________________________
Office Address _________________________________________________________
Dentist's Name ______________________________ Office Phone ______________________________
Health Insurance Company and Number _________________________________________________________
Does your child take any medication and/ or have any allergies?
_________________________________________________________
_________________________________________________________
In case of a major emergency and we could not contact the parents or medical help, is there any medical condition the theater should know about or any medication which the school should have on hand?
_________________________________________________________
Is any restriction of physical activity needed?_________________________________________________________
_________________________________________________________
Is there anything else you would like us to know about your child? _________________________________________________________
_________________________________________________________
_________________________________________________________
List contacts who will assume temporary care of your child if you cannot be reached:
Name
____________________
Relationship
_________________________
Phone
___________________________
Name
____________________
Relationship
_________________________
Phone
___________________________
Family Contact outside of CA
____________________________________
Phone
 ___________________________
(In case of earthquake, phones will work better by calling out of state)

Signing this form states that you know that your child is participating in the Marsh Youth Theater and that you will not sue or expect The Marsh to be legally responsible or pay for damages in the unfortunate event of physical harm or damage to personal belongings.

I give The Marsh Youth Theater permission to include my child's name and/or picture in in-house publications and brochures. The Marsh's website, and in media releases.

I/we, the undersigned parent(s)/guardian(s) of the above named participant grant permission for the participant to participate in all Marsh Youth Theater activities. I/we do hereby release the agents, officers, staff of The Marsh from any and all liability arising from my child's participation.  In case of accident or serious illness, I request MYT to contact me. If the theater is unable to reach me, I hereby authorize the Theater to call the physician indicated above and to follow his/her instructions. If it is impossible to contact this physician, the Theater may make whatever arrangements seems necessary, which we understand will ultimately be the participant's guardian's financial responsibility, should an emergency arise.
_________________________________________________________ _____________________________
Signature of Parent or Guardian Date
_________________________________________________________ _____________________________
Signature of Parent or Guardian Date
------------------------------------------------------------------------------------------------------------------------------

For future use only:
MYT will keep this emergency form. For your convenience, you may update your signature for subsequent classes. Be sure to look over all the information to make sure it is still accurate before you re-sign your name.

_________________________________________________________ _____________________________
Updated Signature of Parent or Guardian Date
_________________________________________________________ _____________________________
Updated Signature of Parent or Guardian Date


Send your Emergency Form to:
The Marsh Youth Theater
1062 Valencia Street (near 22nd),
San Francisco, CA 94110
call: 415-826-5750 x3
fax: 415-643-9070
website: www.themarsh.org
or email:
myt@themarsh.org