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
Birthdate *
Your answer
Gender *
Emergency Contact during Rehearsal time *
Your answer
Cell Phone *
Your answer
Home Phone *
Your answer
Address of Emergency Contact *
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Allergies to Environment/Food/Medications *
Your answer
Medications *
Your answer
Any Current Treatment & Important Past Medical History *
Your answer
Any conditions you wish to disclose that may help us understand your musician and accommodate their needs better: *
Your answer
Parent/Guardian Electronic Signature *
Your answer
Dated, electronically: *
Your answer
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