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As the Parent, Agency Representative, or Legal Guardian, I hereby give consent to Benicia Ballet and Benicia Ballet Theatre to provide all emergency medical or dental care prescribed by a duly licensed physician (MD) or dentist (DDS) for:

This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my dependent. Please disclose any previous or existing injuries or physical conditions of which Benicia Ballet and Benicia Ballet Theatre needs to be aware. Also list any medication allergies.


I agree to hold Benicia Ballet, Inc and Benicia Ballet Theatre (BBT), their premises and personnel harmless for any losses, damages, or liabilities attributable to the negligence of any agent or employee of Benicia Ballet, Inc or BBT or any third party affiliate of the school. The assignee agrees that they have doctor's permission for their child or self to engage in these dance rehearsals and productions and/or the assignee takes sole responsibility for participation in these activities.


PHOTO RELEASE: I hereby grant permission to Benicia Ballet, Inc and Benicia Ballet Theatre to use photographs and/or video taken in 2022-2023 for publications, news releases, news releases, online, and in other communications related to our mission.

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