Medical Consent Form (Summer Camp)

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

Student's Emergency Information

Please provide the emergency contact information listed below.
Mother's Information(Required)
Father's Information(Required)
#1 Relative/Friend Information(Required)
#2 Relative/Friend Information(Required)
Doctor's Information(Required)

Student's Insurance and Health Information

Please select any medical condition(s) the student may have (if any)(Required)
Please list any medical conditions not listed above the student may have that you feel the EPSYOs should be aware of.
Please provide the name of any daily medications the student is taking.
Student's Prescribing Physician Information
Address
Give the name, address, and phone number of the physician who prescribed the medication.
Give the name, address, and phone number of the physician who prescribed the medication.

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 responsible to provide the EPSYO any medical updates/changes for my child through this medical form during the EPSYO Summer Camp 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 responsible to provide the EPSYO any medical updates/changes for my child through this medical form during the EPSYO Summer Camp season for better emergency practice purposes.
Father's Signature/Legal Guardian