GIRLFLY STUDENT WAIVER FORM
SUMMER 2017

To participate in Flyaway Productions GIRLFLY Program, this form must be signed and returned by June 1 2017.

Student's Name*:

Date of Birth*:

Parents/Guardian(s)*:

Address*:

City*:

State*:

Zip Code*:

Parents Cell and/or Best Phone*:

Email*:

Preferred Mode of Communication:
TelephoneEmail
School*:

Grade*:

Medical Information
Health Plan/Insurance Company*:

Policy/ID Number*:

Doctor’s Name*:

Doctor’s Telephone*:

Pertinent Medical Information (allergies, medications, etc.)*:

If necessary, is it acceptable to administer ibuprofen or other non-aspirin over-the-counter drug? YesNo

Emergency Contacts:
1. Emergency Name*:

Cell*:

Home*:

Work*:

2. Emergency Name*:

Cell*:

Home*:

Work*:

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I/We, the undersigned, parent/guardian(s) of the above-named student (the "Student"), hereby consent to the participation of the Student, in Flyaway Productions’ Girlfly Apprenticeship.
I/We acknowledge and agree that I/We will be responsible for transporting the Student to and from Flyaway Productions’ Arts and Activism Apprenticeship.

I/We further discharge and release Flyaway Productions and its trustees, officers, and employees, from any and all liability for injury, loss, damage, obligation, expense, or penalty sustained by the Student arising out of or in connection with the Student’s participation in the Arts and Activism Apprenticeship.

In the event that any serious injury shall occur involving the Student, I wish for Flyaway Productions’ supervisory personnel to take appropriate steps to notify me immediately, but if I am inaccessible for any reason, I authorize whatever medical attention is deemed appropriate for the Student.

I/We understand the following Terms of Stipend/Attendance Policy of the Arts and Activism Apprenticeship:
Stipend of $500 is to be paid to each Student upon completion of the program. Checks will be hand delivered at the final performance.

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