Young Artist Emergency Contact Form

Please complete all fields. All information is 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.

I hereby give my consent that medical care providers and local hospitals be called in the event of a medical emergency. I hereby give authorization to The Cleveland Institute of Art to have my child transported to an emergency center if the situation permits. I understand that The Cleveland Institute of Art will not cover the cost of this transportation.

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.

1. Student First Name *This question is required.

2. Student Last Name *This question is required.

3. Name of person completing this form *This question is required.

4. What is your relation to the student? *This question is required.

5. Emergency Contact First Name *This question is required.

6. Emergency Contact Last Name *This question is required.

7. Emergency Contact Cell Phone *This question is required.

8. Emergency Contact Second Phone (home or work) *This question is required.

9. Emergency Contact Email *This question is required.

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

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