ESYO Ensemble Consent/Emergency Contact Form 25-26

General Permission

In signing this form I give permission for my child to participate in the Empire State Youth Orchestra. This includes all activities and experiences associated with the program. I have received information regarding rehearsal/concert schedule as well as the cost of tuition and I agree to the payment terms.
Initial*
Parent/Musician Handbook
I/We the undersigned acknowledge receipt of the ESYO Parent/Student Handbook and agree to the policies and procedures listed within. Please click here to view the handbook!
Initial*

Playathon

I understand that each spring, all ESYO ensembles perform at Crossgates Mall on the same day. It is ESYO's largest fundraiser of the year, and members are asked to help raise money through ESYO's Peer-to-Peer Fundraiser (tuition only covers 40% of each child's programming). Each member is expected to raise at least $150 towards the goal.
Initial*
Playathon Consent to fundraising expectation
Waiver of Publicity
I/We, the undersigned, give permission for the use of any photos, movies, and audio or video tapings of the Minor’s activities. The materials obtained may be employed with the Empire State Youth Orchestra approval for educational purposes, media coverage, or for publicity benefiting ESYO. I/We also acknowledge that ESYO cannot control photography/filming between students. ESYO cannot be held responsible nor liable for the publication of material created that may contain images of ESYO musicians and/or posted by anyone without ESYO’s knowledge or authorization.

Symphony Orchestra & Chorale: Melodies of Christmas concerts are recorded and broadcast over CBS6/WRGB on Christmas Eve and Christmas Day. In order for your child to participate in Symphony Orchestra/Chorale, you must agree to the following photo release statement: I give permission for my child’s image to be included in any recording of the rehearsals or concerts for use in the TV broadcasting of or any and all promotional materials for the Melodies of Christmas concerts.
Photo Release Consent*

Yes, I give permission.No, I do not give permission
Text Message Notifications

I consent to ESYO contacting me by text message on my provided cell phone. I understand the text message function is only for the purpose of urgent or emergency notifications, i.e. canceled rehearsal due to inclement weather. Text message charges from my cell phone provider may apply. My signature below indicates that I represent...
Musician's Cell Phone
Please enter a valid phone number.
Parent/Caregiver 1

First NameLast Name
Cell Phone
Please enter a valid phone number.
Parent/Caregiver 2

First NameLast Name
Cell Phone
Please enter a valid phone number.
No, I do not consent to text message notifications.

Off-Grounds Permission (Rehearsal Breaks Only)
During scheduled rehearsal breaks, students may be permitted to leave the rehearsal facility without staff supervision. By signing below, I give permission for my child to leave the premises during designated rehearsal breaks and understand that Empire State Youth Orchestra (ESYO) is not responsible for the student while they are off-grounds.*

I give permission for my child to leave the premises unsupervised during rehearsal breaks.I do not give permission for my child to leave the premises during rehearsal breaks.
Student Expectations During Rehearsal Breaks
Students with permission to go off-grounds during breaks are expected to:
- Remain respectful, responsible, and safe at all times.
- Stay in groups or pairs — no one should go off alone.
- Return on time for rehearsal or call time.
- Avoid risky or disruptive behavior.
- Keep a charged phone with them and remain reachable.
- Strictly refrain from alcohol, drugs, tobacco, and vaping products.
- Understand that off-grounds privileges may be revoked at any time due to misconduct.
Acknowledgment & Signature
I, the parent/guardian of
Student Name*
acknowledge that my student is in grade 11 or 12. I hereby request that they be granted permission to leave the rehearsal premises during designated rehearsal breaks.

I understand that:
- I am fully responsible for my student's activities during this off-grounds time.
- My student is not covered by ESYO’s accident insurance while off premises.
- This privilege is contingent upon their responsible behavior as outlined in this agreement.
- This privilege may be revoked if the expectations and responsibilities outlined in this contract are not fulfilled.
Parent/Guardian Signature*

Clear
Student Signature*

Clear
Date*

MonthDayYear
Date

Emergency Contact, Health Information, and Authorization for Medical Treatment

By signing this form, I give permission for my child to receive treatment by a qualified physician in the event of an accident or serious illness, assuming ESYO has made every attempt to contact me. I agree to reimburse ESYO for any such treatment and/or related expenses incurred on my child’s behalf during any ESYO event. I release ESYO, its officers, agents, and employees from any liability related in any way to this authorization and from any responsibility for personal injury or other loss which might occur while engaging in any ESYO activity.
Musician's Date of Birth *

MonthDayYear
Date
Date of Last Tetanus Shot *

MonthDayYear
Date
Parent/Caregiver Name*

First NameLast Name
Parent/Caregiver Name Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caregiver Cell Phone Number*
Please enter a valid phone number.
Parent/Caregiver Day-Time Phone Number*
Please enter a valid phone number.
Parent/Caregiver Email*
example@example.com
Additional Parent/Caregiver or Emergency Contact Name*

First NameLast Name
Additional Parent/Caregiver or Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Parent/Caregiver or Emergency Contact Cell Phone Number*
Please enter a valid phone number.
Additional Parent/Caregiver or Emergency Contact Day-Time Phone Number*
Please enter a valid phone number.
Additional Parent/Caregiver or Emergency Contact Email*
example@example.com

Signatures
Musician Name (Please Print)*

First NameLast Name
Musician Signature*

Clear
Date*

MonthDayYear
Date
Parent/Caregiver Name (Please Print)*

First NameLast Name
Parent/Caregiver Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

ESYO Ensemble Consent/Emergency Contact Form

General Permission

Parent/Musician Handbook

Playathon

Waiver of Publicity

Text Message Notifications

Off-Grounds Permission (Rehearsal Breaks Only)

Student Expectations During Rehearsal Breaks

Acknowledgment & Signature

Emergency Contact, Health Information, and Authorization for Medical Treatment

Medication/Purpose/Special Instructions

Food and Dietary Restrictions

Signatures