2013-­‐  2014   Emergency  Contact  Information   and  Medical  Release  

  1.   First  name  of  student  _______________________   Last  name  of  student  _______________________________     Student’s  age  (Sept.  1,  2013)  _______________   Student’s  date  of  birth  _____________________________     Orchestra  (circle):   Mozart  Players   Amadeus  Players  

Philharmonia  

Youth  Symphony  

2.  First  name  of  sibling  _________________________   Last  name  of  student  _______________________________     Student’s  age  (Sept.  1,  2013)  _______________   Student’s  date  of  birth  _____________________________     Orchestra  (circle):   Mozart  Players   Amadeus  Players  

Philharmonia  

Youth  Symphony  

3.  First  name  of  sibling  _________________________   Last  name  of  student  _______________________________     Student’s  age  (Sept.  1,  2013)  _______________   Student’s  date  of  birth  _____________________________     Orchestra  (circle):   Mozart  Players   Amadeus  Players    

Philharmonia  

Youth  Symphony  

In  case  of  emergency,  contact:   Name  ____________________________________________   Relationship  ________________________________________   Daytime  phone  _________________________________   Evening  phone  (if  different)_______________________   Name  ____________________________________________   Relationship  ________________________________________   Daytime  phone  _________________________________   Evening  phone  (if  different)_______________________   Please  list  any  medical  conditions  (e.g.,  allergies)  that  SYSA  should  be  aware  of:  _________________   _____________________________________________________________________________________________________________   Physician’s  name  _______________________________   Physician’s  phone  __________________________________     Parent/Guardian  Authorization   My  son/daughter  has  my  permission  to  participate  in  all  SYSA  events,  rehearsal,  and  concerts.     In  case  of  emergency  when  either  there  is  not  enough  time  or  I  cannot  be  reached,  I  hereby   give  permission  for  my  child,  a  member  of  the  Salem  Youth  Symphony  Association,  to  receive   medical  treatment  deemed  necessary  by  an  adult  representative  of  SYSA.    All  reasonable   efforts  will  be  made  to  contact  me  if  an  emergency  occurs.     ___________________________________________________   _______________________________________________________   Printed  name   Relationship     ___________________________________________________   _______________________________________________________   Signature   Date     Salem  Youth  Symphony   P.O.  Box  1113,  Salem,  OR  97308   www.salemyouthsyphony.org   503.485.2244   [email protected]