Andy's Summer Playhouse

Andy’s Summer Playhouse is an innovative summer youth theater located in southern New Hampshire. Every summer we produce original works that are performed by local artists aged eight to eighteen, with direction and mentoring by professional artists from New Hampshire and beyond.

innovative summer youth theater located in southern New Hampshire

Medical Release and Emergency Contact Form

Please Note:

Andy’s staff will make every effort to reach you or the designated Emergency Contact Person in the case of an emergency. However, if no one can be reached, by submitting this form you are giving your permission for the Andy’s staff to secure proper medical treatment for your child.

Parent/Guardian Completing Form *
Parent/Guardian Completing Form
Child's Name *
Child's Name
Address
Address
Home Phone
Home Phone
Date of Birth
Date of Birth
First Parent/Guardian
First Parent/Guardian Name
First Parent/Guardian Name
First Parent/Guardian Cell Phone
First Parent/Guardian Cell Phone
First Parent/Guardian Home Phone
First Parent/Guardian Home Phone
First Parent/Guardian Work Phone
First Parent/Guardian Work Phone
Second Parent/Guardian
Second Parent/Guardian Name
Second Parent/Guardian Name
Second Parent/Guardian Cell Phone
Second Parent/Guardian Cell Phone
Second Parent/Guardian Home Phone
Second Parent/Guardian Home Phone
Second Parent/Guardian Work Phone
Second Parent/Guardian Work Phone
Additional Emergency Contact
Additional Emergency Contact Name
Additional Emergency Contact Name
Additional Emergency Contact Cell Phone
Additional Emergency Contact Cell Phone
Additional Emergency Contact Home Phone
Additional Emergency Contact Home Phone
Medical Information
Primary Care Physician
Primary Care Physician
Primary Care Physician Phone
Primary Care Physician Phone
If your child has a headache or other mild pain do you give us permission to distribute label-recommended dosages of Tylenol or Ibuprofen?
Date of Child’s last tetanus shot:
Date of Child’s last tetanus shot: