Scoil Rince na hEasan Permission and Medical Release

   
   Irish dancing is a high impact aerobic activity. You should consult your physician before participating in such an activity. Even if you are in good physical condition, injury can result from repetitive activity. Accidents can occur by dancing on various surfaces. You are responsible for determining the appropriateness of such activity for you or your child. It is also recommended that you maintain accidental or medical benefit coverage on your own.
   We ask that you complete this to acknowledge these circumstances and inform us of any limitations for yourself or your child.


Student:_____________________________ Birth date:________________


Age:_________ Sex: ______


Name of parent or guardian (if under 18):______________________________________


Home Phone: __________________________ Work Phone: _______________________

Physician’s name: ____________________________ Phone:______________________

Emergency contact name:_________________________ Phone:____________________

Health conditions or allergies: _______________________________________________


I give permission for full participation in Scoil Rince na hEasan programs, subject to the attached limitations. I understand that I am responsible to maintain health insurance or pay for medical care. 

In case of an emergency, I understand that every effort will be made to contact the appropriate people. In the event that I cannot be reached, I give permission to the licensed medical practitioner selected by the adult in charge to secure proper treatment, including hospitalization, medications, or surgery for me or my child.  

Signature of parent, guardian, or adult student: ____________________________ 

Date: ________________________