ACDA NAME Honor Choir Medical Permission Form and Liability Waiver
Convention Name | City, State - Date

Required of all participants.  Please type or print in black ink.
Participant’s Name: 																(Last)				(First)				(Middle)
Health Insurance Provider: 							 Policy Number: 				
List all prescription medications you are currently or might be taking:
	Name: 				 Dosage: 	 Frequency: 			 Reason:				
	Name: 				 Dosage: 	 Frequency: 			 Reason:				
List any known food, drug, animal, or environmental allergies: 									
Circle any conditions for which the participant is currently receiving medical treatment:
	Insulin Dependent		Insulin pump	Fainting		Inhaler		Auto Immune Disorders
	ADHD			ADD		Depression	Other:
List any other medical conditions for which the participant is being treated: 							
															
Physicians Name: 							 Office Phone: (		)			
Address:								 Home Phone: (		)				
								 Cell Phone:    (		)				
The designated Honor Choir Chair, Honor Choir Chair Assistant, and/or Honor Choir Coordinator, and the designated chaperone (if other than a parent) have my permission to administer (dual person observed and documented) the following to the participant if warranted: 
(Circle)		Tylenol		Ibuprofen			Imodium		Dramamine
		Pepto-Bismol 	Maalox			Tums		Other:
If you wish to be called before any over the counter medication is dispensed, please initial here: 			
If the participant listed above should require medical attention while participating in the ACDA NAME Honor Choir in CITY, STATE, DATE, NAME, Honor Choir Coordinator; NAME, Honor Choir Co-Chairs and the designated chaperone has my permission to treat on site or take said participant to a doctor, hospital, or any other medical facility for necessary medical treatment, and I here by authorize the release off medical information included on this document to the health care provider administering medical treatment to the participant.  
I hereby release, indemnify and hold harmless the American Choral Directors Association (“ACDA”), its trustees, employees, volunteer workers, students, agents and assigns from any and all liability, damage, claim of any nature whatsoever arising out of or in any way related to my/my child’s participation in the ACDA NAME Honor Choir in CITY, STATE.
Participating in any activity is an acceptance of some risk of injury.  I agree that my/my child’s safety is primarily dependent upon taking proper care of oneself.  Despite precautions, accidents and injuries may occur and injury and/or loss or damage to personal property may occur as a result of participating in the ACDA NAME Honor Choir;  there fore, I assume all risks related to participating in the ACDA NAME Honor Choir.  I also hereby acknowledge that the American Choral Directors Association, its trustees, employees, volunteer workers, students agents and assigns assume no liability whatsoever for personal injuries or property damage that may arise out of my/my child’s participation in the ACDA NAME Honor Choir.  
My signature on this form indicates that I have read, understood, and freely signed this agreement.  I expressly agree that this agreement shall be construed and enforced in accordance with laws of the State of Oklahoma, with Oklahoma County being the court of exclusive jurisdiction, and I consent to the jurisdiction of the State of Oklahoma and of the courts of Oklahoma County.  I agree that this waiver and release is intended to be as broad and inclusive as permitted under the laws of the State of Oklahoma so that if any portion hereof is held invalid, the balance shall continue in full legal force and effect. 
This form must be signed in the presence of a Notary Public.
Parent/Guardian Name (Print): 						 Signature: 					
Home Phone: (		)				 Cell Phone:    (		)				
Work Phone: (		)				 Other Phone: (		)				
Signed in my presence this 		 day of 			 (month), 		 (year).
Witness my hand and seal this 		 day of 			 (month), 		 (year).
Notary Public: 							 Notary Seal: 
My Commission Expires: 						
This is not a legal document without the signature and seal of a Notary Public.
*A scanned PDF of this executed and notarized Waiver or a copy thereof shall be deemed as an original for all purposes.