Medical consent

Medical Consent Form

EPSYO Student's Name(Required)
Student's Home Address(Required)

Student's Emergency Information

Feel free to provide as many emergency contacts as you'd like.
Mother's Information(Required)
Father's Information(Required)
Doctor's Information(Required)
#1 Relative/Friend Information(Required)
#2 Relative/Friend Information(Required)

Student's Insurance and Health Information

Please list student's Medical Condition (if any)(Required)
Please list above any medical problems your child may have and you feel the EPSYOs should be aware of.
Please provide the name of any daily medications your child is taking.
Student's Prescribing Physician Information
Give the name, address, and phone number of the physician who prescribed the medication.
Address

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 2023-2024 EPSYO season for better emergency practice purposes.
Mother's Signature/Legal Guardian
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 2023-2024 EPSYO season for better emergency practice purposes.
Father's Signature/Legal Guardian