Emergency Medical Release

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?
Student #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 Contact
Contact #1 - Relationship to child:*
Name*
First Last
Contact #1 - Cell Phone*
Contact #1 - Other Phone
Contact #2 - Relationship to child:*
Name*
First Last
Contact #2 - Cell Phone*
Contact #2 - Other Phone
Additional 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.

Missouri Street Theatre (707)422-1598 : 1125 Missouri St # 1000, Fairfield, CA 94533

Emergency Medical Release – Online Form

Emergency Contact