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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 13, 2024

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's 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*
Second Participant's 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*
Third Participant's 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*
Fourth Participant's 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*
Fifth Participant's 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*
Sixth Participant's 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*
Seventh Participant's 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*
Eighth Participant's 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*
Ninth Participant's 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*
Tenth Participant's 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*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's 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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