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Music Makers Medical Form and Liability Waiver
Student Information
Name of Minor (Student)
*
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.
Student Allergies to Environment/Food/Medications:
*
Please provide a list of any medications this student is taking, both prescription and over the counter:
*
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.
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I agree to the terms specified above
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Liability Waiver
Please review the following document with your student.
Note: If this image appears too small on your screen, try selecting a single page view by clicking the 3 horizontal lines in the upper left hand corner of the control bar OR download the document.
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I agree to the terms specified above
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