Medical Consent Form

Medical consent

EPSYO Student's Name(Required)

First Last

EPSYO Student's Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Student's Emergency Information (You can type as many emergency numbers as available)

Mother's Information(Required)

Full Name Emergency Number

Father's Information(Required)

Full Name Emergency Nunmber

Doctor's Information(Required)

Full Name Emergency Nunmber

#1 Friend/Relative Information(Required)

Full Name Emergency Nunmber

#2 Friend/Relative Information(Required)

Full Name Emergency Nunmber

Student's Insurance and Health Information

Name of Insurance/group(Required)

Number of Insurance/group(Required)

Please List Student's Medical Condition (if any)(Required)

Allergies

Heart Problem

Diabetes

Convulsions

Astma

Other

Not Applicable (No Medical Condition to be Listed)

Explain Other Student's Medical Condition (If any)

Please list above any medical problems your child may have and you feel the EPSYOs should be aware of.

Student's Daily Medication(s)(If Any)

Please provide the name of any daily medications your child is taking.

Student's Prescribing Physician Information

First Last

Give the name, address, and phone number of the physician who prescribed the medication.

Address

Street Address

Phone

EPSYO Agreement

I do hereby authorize the authorities and staff of the El Paso Symphony Youth Orchestras (EPSYO) to permit its designated representatives to give consent to a physician and/or hospital for immediate and/or emergency medical and/or surgical treatment when necessary to our son/daughter for sustained injuries or sickness requiring emergency treatment during EPSYO events provided such events have an authorized representative of the EPSYO present. It is understood that the EPSYO or its representatives do not assume any financial responsibilities for any expenses that might be incurred for said emergency treatment, and the EPSYO will notify us as soon as possible following the emergency, but in no way is treatment to be delayed until we have been notified. I understand that EPSYO authorities and staff may inform other school personnel of my child’s medical condition(s) and/or disability when necessary for my child’s well-being.

By typing my name below, I am electronically signing this medical form, I am also responsible to provide to the EPSYO via email, medical updates or changes for my child in this medical form throughout the EPSYO season 2022-2023 for better emergency practice purposes.

Full Name Signing Date

Mother's Signature/Legal Guardian

Full Name Signing Date

Father's Signature/Legal Guardian

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