Colorado Medical Release Form 1Colorado Medical Release Form 1
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Colorado School of Acting
Navy Teens Performing Arts Camp
7500 W. Mississippi Ave Ste. B150
Lakewood ,CO 80226
[email protected]


As the parent/legal guardian of ___________________________, I request
that in my absence the above-named camper be admitted to any hospital or
medical facility for diagnosis and treatment. I request and authorize
physicians, dentists, and staff, duly licensed as Doctors of Medicine or
Doctors of Dentistry or other such licensed technicians or nurses, to perform
any diagnostic procedures, treatment procedures, operative procedures and
x-ray treatment of the above minor. I have not been given a guarantee as to
the results of examination or treatment. I authorize the hospital or medical
facility to dispose of any specimen or tissue taken from the above-named
Date of Players Birth_____/_____/_____
Date of last Tetanus Booster____/____/____
Month Day Year Month Day Year