Medical Consent Form - EPSYO | El Paso Symphony Youth Orchestras

Medical consent & Membership/Media Release

EPSYO MEDICAL CONSENT & HANDBOOK AGREEMENT FORM 2024-2025

EPSYO STUDENT'S NAME(Required)

First Last

STUDENT'S HOME ADDRESS(Required)

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

STUDENT'S EMERGENCY INFORMATION

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 Relative/Friend Information(Required)

Full Name Emergency Nunmber

#2 Relative/Friend Information

Full Name Emergency Nunmber

STUDENT'S INSURANCE & 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 Medical Conditions (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

MEDICAL AGREEMENT

I do hereby authorize the 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 2024-2025 EPSYO season for better emergency practice purposes.(Required)

Full Name Signing Date

Mother/Legal Guardian Signature

Full Name Signing Date

Father/Legal Guardian Signature

HANDBOOK AGREEMENT

I have read and understood the content of the Membership Handbook and my responsibilities as an EPSYO member. I agree to abide by all the rules of the EPSYO and understand that failure to follow the rules laid out in the handbook may result in my dismissal without refund of fees. I understand that I am responsible to participate in the Vertical Raise fundraiser and to make a raffle tuition payment. (Raffle total is equivalent to $100 and is divided into two different sales of $50 each. The raffle is part of your child’s tuition and is non-negotiable.) **not applicable for summer camp** I understand that EPSYO activities may be recorded (audio and/or video) and photographed for use in both EPSYO and El Paso Symphony Orchestra (EPSO) publications, advertising, promotions, and website. I hereby agree to allow the EPSYO to use my photographic or video likeness in any publicity material, either printed or broadcast. All materials will remain the sole property of the EPSYO.

Parent/Guardian Name(Required)

First Last

Parent/Guardian E-Signature(Required)

Date

Student Name(Required)

First Last

Student E-Signature(Required)

Date

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