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Joyce Lemos Aerial Arts Dance Academy, LLC (JLAADA) Medical Release Form

I hereby give permission for any and all medical attention to be administered to my child in the event of accident, injury, sickness, etc., at any necessary emergency facility, until such time as I may be contacted.

I also assume the responsibility for the payment of any such treatment.

Today's Date: May 15, 2025

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Participant's Age Acknowledgment*
Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Insurance Company:
Policy #
Child's Physician
Physician's Phone
Preferred Hospital

Medical Conditions

Current Medications

Known Allergies to Foods or Medications
Last Tetanus
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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