Orchestra Group Travel Medical Release Form
Participant Information
Student Name:
Date of Birth:
School:
Grade:
Home Address:
City:
State:
Zip:
Parent/Guardian Information
Parent/Guardian Name:
Phone (Primary):
Phone (Secondary):
Email Address:
Emergency Contacts
Name:
Relation:
Phone:
Medical Information
Allergies or Medical Conditions:
Medications (list, include dosage & instructions):
Health Insurance Company:
Policy/Group Number:
Physician Name:
Physician Phone:
Authorization & Consent
I hereby give my permission for the above-named participant to attend and participate in all orchestra group travel activities. In the event of illness or injury, I authorize the adult chaperones to obtain necessary medical treatment as deemed appropriate.
I understand that all reasonable effort will be made to contact me before such action is taken. I accept responsibility for any expenses incurred in obtaining medical treatment.
Parent/Guardian Signature:
Date: