I, the undersigned, parent/person having legal custody/legal guardianship of the above named minor, do hereby authorize the staff and/or volunteers of the Broadway Arts Lab Company, as agent(s) for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practice Act, whether such diagnosis or treatment is rendered at a physician's office, medical group, clinic or hospital.
I understand that although care is reviewed and supervised by a physician, actual care may be rendered by physician extenders (i.e., physician assistants, nurse practitioners).
It is understood that this authorization, made in advance of any specific diagnosis, treatment or hospital care being required,
is given to provide authority to the above described agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable.
I hereby authorize any physician's office or hospital which has provided treatment to the named minor to surrender physical custody of such minor to my above named agent(s) upon the completion of treatment.
This authorization shall remain effective until the arrival on the scene of the parent(s)/person having legal custody/legal guardianship of named minor child (or their designee) at which time the staff and/or volunteers of the Broadway Arts Lab Company will no longer be responsible for decisions regarding diagnosis and/or treatment of named minor child.
This authorization shall remain in effect through the rehearsals and performances in which the above named minor is participating, unless sooner revoked in writing.
I agree to indemnify and hold harmless the Broadway Arts Lab Company, its employees and volunteers, from and against any and all liability for any injury which may be suffered by the above named minor during rehearsals and/or performances conducted by the Broadway Arts Lab Company.