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) *
Your answer
Home Address *
Your answer
Birthdate *
Your answer
Gender *
Parent/Legal Guardian Name *
Your answer
Address *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Allergies to Medications *
Your answer
Other Allergies *
Your answer
Medications *
Your answer
All conditions for which the child is receiving treatment: *
Your answer
Important Past Medical History *
Your answer
Parent/Guardian Electronic Signature *
Your answer
Dated, electronically: *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms