All-VA Orff Ensemble Student Medical Information

All-VA Orff Ensemble Student Medical Information

This form should be completed by the parent/guardian of each student invited to participate in the All-VA Orff Ensemble November 20-21, 2024. These forms are confidential and are to be kept in the music teacher’s possession and shared as necessary with a school-approved chaperone that may accompany the student(s). Music teachers are required to discuss and review confidentiality and accessibility to student medical information with school administration.
Music Program Information
Student's Elementary School Name:*
Student's Elementary School Music Teacher.*

First NameLast Name
Student Medical Information
Student Name: *

First NameLast Name
Student's Age: *
Student T-shirt Size:
Name of Parent/Guardian: *

First NameLast Name
Parent/Guardian Email:*
example@example.com
Home Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:

Area CodePhone Number
Parent/Guardian Cell Phone:*

Area CodePhone Number
Emergency Contact Information:
Name of Emergency Contact: *

First NameLast Name
Emergency Contact Phone #: *

Area CodePhone Number
Relationship to Student: *
Please list any additional emergency contact information below....
If your child is taking medicine that will need to be administered during rehearsal, please contact your child’s music teacher to make arrangements.
Please list any medical concerns or food allergies for your child...
Additional contacts or concerns...
In case of an emergency, I/We the Parent(s)/Guardian(s) understand that every effort will be made to contact the parent(s), guardian(s), or designated emergency contact listed above. In the event a parent, guardian, or designated emergency contact cannot be reached, I/We hereby, in an emergency situation, give permission to the physician selected by the Professional Staff to hospitalize and provide treatment for my child as named above.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

All-VA Orff Ensemble Student Medical Information

Music Program Information

Student Medical Information

Emergency Contact Information: