YPC National Studio - Conductor Health Information Form

YPC National Studio – Conductor Health Information Form

YPC National Studio Conductor - Health Information Form

Studio Participant Contact Information

Name(Required)

First Last

Mobile Phone(Required)

Home Phone

Email(Required)

Health & Emergency Information

In case of medical or surgical necessity or emergency, I understand that YPC National will make every effort to reach myself or the emergency contact regarding medical treatment. in the event that we are not available, I hereby give my permission to the physician selected by the YPC National Staff and Chaperones to provide whatever medical or surgical treatment is necessary. The provided health history is correct, and my child has permission to engage in all prescribed activities except as noted. I (we) hereby give the adult staff and chaperones of YPC permission to authorize medical treatment for my (our) chorister named above, as they deem necessary or reasonable, without additional permission from me. I (we) agree to assume responsibility for all costs advanced by YPC in order to obtain medical care for my (our) chorister. In the event that the adult representatives of YPC decide that my (our) chorister must leave an event for medical or unforeseen reasons, I (we) agree to be responsible for any costs related to my chorister's trip home from any event. I (we) understand that such a decision is solely at the discretion of the adult representatives of YPC.

Date of Birth(Required)

Emergency Contact Name(Required)

First Last

Phone Number(Required)

Relation(Required)

Please share allergies that you have (food, pollen, etc.):(Required)

Do you carry an epi-pen?(Required)

Yes

For which allergy?

Do you have asthma?(Required)

Yes

Do you carry an inhaler?

Yes

Please tell us information we need to know should you not be responsive (including medication you require):(Required)

YPC National Studio – Conductor Health Information Form