GYSO Medical Release & Waiver
This form is designed to ensure the health and safety of all GYSO members during any and all GSO/GYSO events and activities.
By completing this form, you elect to grant permission for GSO/GYSO staff to arrange for and consent to emergency medical procedures and/or treatment at their discretion. Further, you agree to release, indemnify, and hold harmless or reimburse the Georgia Symphony Orchestra and Georgia Youth Symphony Orchestra and all associated members, employees, representatives, and approved supervisors from and forever promise not to sue them on any and all claims, demands, rights, causes of action, liabilities, losses, damages, costs and expenses (including attorneys’ fees) arising out of or in any manner relating to the student’s participation in GYSO events and activities.
Email address *
GYSO Student First, Middle, Last Name *
Your answer
GYSO Ensemble(s). Check all that apply. *
Required
Date of Birth: *
MM
/
DD
/
YYYY
Full Home Address: *
Your answer
In Case of Emergency Contact Name & Cell #: *
Your answer
Secondary ICE Contact Name & Cell #: *
Your answer
Medical Conditions: *
Your answer
All Known Allergies: *
Your answer
Medications: *
Your answer
Insurance Provider: *
Your answer
Insurance Policy #: *
Your answer
Insurance Group #: *
Your answer
Insurance Policy Holder Name: *
Your answer
Additional Notes & Information:
Your answer
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