OAYO Medical Authorization Form
I, as the parent or legal guardian of the minor listed below, give my authorization to the staff members of Omaha Area Youth Orchestras, to administer first aid to the minor listed below for minor injuries such as scrapes and bruises. In case of more serious injury or illness, attempts will be made to contact me. In case of a life threatening medical emergency, I authorize the staff of Omaha Area Youth Orchestras to seek emergency medical treatment for the minor listed below including transportation by ambulance to an emergency medical facility.
Full Name of Minor (Musician)
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Home Address
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Birthdate
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Gender
Parent/Legal Guardian Name
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Address
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Home Phone
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Work Phone
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Cell Phone
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Physician's Name
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Physician's Phone Number
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Allergies to Medications
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Other Allergies
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Medications
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All conditions for which the child is receiving treatment:
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Important Past Medical History
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Parent/Guardian Electronic Signature
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Dated, electronically:
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