Emergency Medical Release – Online Form I, the the undersigned parent/guardian authorize Harbor Theatrical Group (a.k.a Missouri Street Theatre) to server as agents for the undersigned and grant them the right to consent permission of any X-ray, examination, anesthetic, medical or surgical diagnosis, treatment and/or Hospital Care, to be rendered to the minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state of California, when the need for such treatment in immediate, and when efforts to contact me (us) are unsuccessful. This authorization shall be valid for the period of time during which my child is signed up for classes and/or performances and/or otherwise attending Missouri Street Theatre. I do hereby indemnify and hold harmless the physician, hospital, and other persons who act in reliance upon this authorization. This medical release is regarding the following session(s): (required)* Broadway Summer Camp Disney Summer Camp Rock-n-Roll Summer Camp Spring Production Summer Production Fall Production Winter Production -Please select all that apply.Consent for how many children?12345Student #1 Name* First Last Student #2 Name* First Last Student #3 Name* First Last Student #4 Name* First Last Student #5 Name* First Last Parent / Guardian name:* First Last Emergency ContactContact #1 - Relationship to child:*MomDadGrandmaGrandpaSibling (over 18)Other (relative)Other (not relative)Name* First Last Contact #1 - Cell Phone*Contact #1 - Other PhoneContact #2 - Relationship to child:*MomDadGrandmaGrandpaSibling (over 18)Other (relative)Other (not relative)Name* First Last Contact #2 - Cell Phone*Contact #2 - Other PhoneAdditional comments / important information Please use this field to describe any specific medical information you would like us to know and keep on record with respect to any of the children / students that will participate in the MST camps and lessons. Be specific and indicate to which child the information pertains to. By pressing Submit, I agree to the emergency medical consent stated above.