Medical Release Form - Music In The Summer

Fill in and print this release form. If necessary, please attach separate sheet(s).

Emergency Contact Information

Name:

Date of Birth:

Gender:

M F

Health Card Number:

Travel Medical Insurance Company:

Travel Medical Insurance Policy Number:

Allergies:

Dietary and/or Health Restrictions:

Medications currently taking & instructions for use:

Recent illness or medical condition:

Restrictions on activities:

Emergency Contact Information

Parent / Guardian 1:

First Name:

Last Name:

Home Phone:

Cellular (mobile) phone:

Parent / Guardian 2:

First Name:

Last Name:

Home Phone:

Cellular (mobile) phone:

Other than Parent / Guardian:

First Name:

Last Name:

Home Phone:

Cellular (mobile) phone:

I give permission for my son/daughter to join JVL Summer School for Performing Arts in YMCA Geneva Park, Orillia, Canada, June 30 - 10, 2018. I give permission to the School Staff to authorize medical treatment for my son/daughter in case of emergency.

Name and signature of parent or guardian:
__________________________________________________________________________ Date ______________