Please type your name and today’s date above to acknowledge authorization. I certify that I am the parent or legal guardian of the above listed minor, and as such, I hereby convey temporary authority to any adult employee or agent of the Winter Springs Performing Arts Center Foundation, Inc (the “WSPA”) for the sole purpose of obtaining emergency medical or dental care for the Minor that is recommended by a licensed healthcare provider to whom the Minor was presented for treatment and as may be deemed necessary for the well-being of the Minor when not accompanied by a parent / legal guardian, or should either parent / legal guardian be unreachable by telephone, text message, or e-mail.

I hearby release any licensed healthcare provider providing medical care to the Minor in reliance of this form from liability relating to such healthcare provider’s acceptance of my substitute caregiver’s consent. I further hold harmless and release WSPA, it’s employees, and agents from any liability associated with their efforts and decision to obtain medical care for the Minor.

I further approve and empower any adult employee or agent of WSPA with the authority to arrange and / or consent to any and all emergency medical or dental care treatment of the Minor in my absence. I hereby assume full financial responsibility for any medical care or treatment provided by any health care provider who provides medical care to the Minor.

This Medical Authorization And Release Form shall remain in effect until it is revoked by notifying, in writing, the appropriate healthcare providers and WSPA that I wish to revoke it.