Medical Release Form

I am aware that during any Impulse Youth Arts Organization, Rhythm Regiment Drum and Brass Corps
(herein collectively referred to as “IYAO”) activities, including without limitation competitions,
rehearsals and trips, certain hazards may occur, including but not limited to, the hazards of accidents or
illness, which may occur at places without medical facilities, hazards created by the forces of nature and
hazards of travel by air, train, bus, automobile and other means, including walking.

I understand and do hereby assume all of the above-mentioned risks and will hold IYAO harmless from
any and all liability whatsoever which may arise out of participation in any activities arranged for the
participant by IYAO, or during any travel in private vehicles to and from any IYAO rehearsals or
functions. This document shall serve as a release of all claims for personal injury to the participant and an
assumption of risk binding upon my heirs, executor and administrators, and all members of my family.
In an event of participant’s illness, I do hereby authorize any of the directors, officers, managers or
chaperones of IYAO who are present at the place of occurrence to consent to whatever x-ray examination,
anesthetic, medical, surgical, or dental diagnosis, treatment, and/or hospital care that may be considered
necessary for the participant in the best judgment of the attending physician, surgeon, or dentist and to be
performed by or under the supervision of a member of the medical staff of the hospital or facility
furnishing medical or dental services. I recognize that the directors, officers, managers or chaperones
consenting to such health care may reasonably and in good faith rely upon the advice furnished to him or
her by the attending licensed health care provider(s).

I understand that “IYAO” may not provide transportation to a scheduled event or trip. All
members who use private transportation as part of a trip or tour shall understand that they waive
claims against “IYAO” in the event of accident, injury or death.


INDEMNIFICATION: I further agree to hold harmless, defend, and indemnify “IYAO” from any and
all liability as defined above, resulting from, or in any manner arising out of any negligence of the
member during a scheduled “IYAO” activity.
I have read the Release of Liability, Assumption of Risk and Medical Consent. I agree
voluntarily with full knowledge of the significance of these terms
Do you agree to the statement above. Sign Yes or No and your name. (if under 18 it must be signed by a parent/guardian) *
Your answer
Participant Name *
Your answer
Best Email to reach you at *
Your answer
What Section are you participating in? *
IF UNDER 18, Primary Parent/Guardian Name *
Your answer
Best Email to reach the Parent/Guardian at? *
Your answer
Primary Parent/Guardian Emergency Contact Phone Number *
Your answer
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