2013-‐ 2014 Emergency Contact Information and Medical Release
1. First name of student _______________________ Last name of student _______________________________ Student’s age (Sept. 1, 2013) _______________ Student’s date of birth _____________________________ Orchestra (circle): Mozart Players Amadeus Players
Philharmonia
Youth Symphony
2. First name of sibling _________________________ Last name of student _______________________________ Student’s age (Sept. 1, 2013) _______________ Student’s date of birth _____________________________ Orchestra (circle): Mozart Players Amadeus Players
Philharmonia
Youth Symphony
3. First name of sibling _________________________ Last name of student _______________________________ Student’s age (Sept. 1, 2013) _______________ Student’s date of birth _____________________________ Orchestra (circle): Mozart Players Amadeus Players
Philharmonia
Youth Symphony
In case of emergency, contact: Name ____________________________________________ Relationship ________________________________________ Daytime phone _________________________________ Evening phone (if different)_______________________ Name ____________________________________________ Relationship ________________________________________ Daytime phone _________________________________ Evening phone (if different)_______________________ Please list any medical conditions (e.g., allergies) that SYSA should be aware of: _________________ _____________________________________________________________________________________________________________ Physician’s name _______________________________ Physician’s phone __________________________________ Parent/Guardian Authorization My son/daughter has my permission to participate in all SYSA events, rehearsal, and concerts. In case of emergency when either there is not enough time or I cannot be reached, I hereby give permission for my child, a member of the Salem Youth Symphony Association, to receive medical treatment deemed necessary by an adult representative of SYSA. All reasonable efforts will be made to contact me if an emergency occurs. ___________________________________________________ _______________________________________________________ Printed name Relationship ___________________________________________________ _______________________________________________________ Signature Date Salem Youth Symphony P.O. Box 1113, Salem, OR 97308 www.salemyouthsyphony.org 503.485.2244
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