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Medical Release Form
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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, August 3 - 17, 2021. 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 ______________
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MUSIC
in the
Summer
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