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WYSO Medical Form and Liability Waiver
Student Information
Name of Minor (Student)
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First Name
Last Name
Name of Primary Care Physician
First Name
Last Name
Primary Care Physician's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student Allergies to Environment/Food/Medications. If none, please enter NA
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Please provide a list of any medications this student is taking, both prescription and over the counter:
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By checking any of the boxes below, adult permission is granted to take any of the following medications during rehearsals or while on tour:
Tylenol (acetaminophen)
Ibuprofen
Any current treatments and important past medical history:
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Please share any information you feel will be helpful to our staff in best supporting this student. Helpful information includes health concerns beyond those already listed, special or extenuating family information, IEP (individualized education plan) or any specialized education plans, etc.).
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Medical Release
I, as the parent or legal guardian of the minor listed above, give my authorization (via electronic signature) to the staff members of the Wisconsin Youth Symphony Orchestras, to administer first aid to the minor listed above for minor injuries such as scrapes and bruises. In case of more serious injury or illness, attempts will be made to contact me. In case of a life threatening medical emergency, I authorize the staff of Wisconsin Youth Symphony Orchestras to seek emergency medical treatment for the minor listed above, including transportation by ambulance to an emergency medical facility.
Type a question
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I agree to the terms specified above
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Liability Waiver
I, the undersigned parent or legal guardian, authorize the above-named student (the “Student”) to participate in the Wisconsin Youth Symphony Orchestras (“WYSO”). I agree to hold harmless and release from liability WYSO and their respective directors, officers, employees, agents and volunteers (collectively, the “Released Parties”) relating to any action, proceeding, claim or damage that may arise as a result of the Student’s participation in WYSO, including (but not limited to) physical, emotional, or mental injuries. I understand that although the Released Parties may be present at performances and other WYSO activities (the “Activities”), the Released Parties will not be responsible for supervision of the Student. I am solely responsible for supervising the Student in connection with the Activities. I and the Student shall comply with all applicable laws in connection with the Activities, including all laws concerning alcohol and minors. I understand that the Activities may take place at various locations within the United States. I agree that I am solely responsible for the transportation of the Student in connection with the Activities and for all risks associated with travel, regardless of whether the Released Parties arrange transportation in connection with the Activities. I understand that the Activities may include performance opportunities and that the Student will come into contact with professional musicians, stage hands, sound engineers, audience members and others in connection with the Activities who are not under the control of the Released Parties. I understand and assume all risks associated with the Activities, and I agree to hold harmless and release from liability the Released Parties for any injuries in connection with the Activities (other than any injuries caused by the gross negligence or willful misconduct of the Released Parties).
Type a question
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I agree to the terms specified above
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