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WYSO Medical and Media Consent Forms
Student Information
Name of Minor (Student)
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Name of Primary Contact (Legal Guardian)
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First Name
Last Name
Primary Contact Cell Phone Number
*
Please enter a valid phone number.
Primary Contact Home Phone Number
Please enter a valid phone number.
Name of Emergency Contact
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First Name
Last Name
Emergency Contact Cell Phone Number
*
Please enter a valid phone number.
Emergency Contact Home Phone Number
Please enter a valid phone number.
Relationship to Minor
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Emergency Contact Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Primary Care Physician
First Name
Last Name
Primary Care Physician's Phone Number
Please enter a valid phone number.
Student Allergies to Environment/Food/Medications. If none, please enter NA
*
Please provide a list of any medications this student is taking, both prescription and over the counter:
By checking any of the boxes below, adult permission is granted to take any of the following medications during rehearsals or while on tour:
Tylenol (acetaminophen)
Ibuprofen
Any current treatments and important past medical history:
Please share any information you feel will be helpful to our staff in best supporting this student. Helpful information includes health concerns beyond those already listed, special or extenuating family information, IEP (individualized education plan) or any specialized education plans, etc.).
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Medical Release
I, as the parent or legal guardian of the minor listed above, give my authorization (via electronic signature) to the staff members of the Wisconsin Youth Symphony Orchestras, to administer first aid to the minor listed above for minor injuries such as scrapes and bruises. In case of more serious injury or illness, attempts will be made to contact me. In case of a life threatening medical emergency, I authorize the staff of Wisconsin Youth Symphony Orchestras to seek emergency medical treatment for the minor listed above, including transportation by ambulance to an emergency medical facility.
Parent/Guardian Signature for Authorization
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Section II - Covid-19 Release
I acknowledge and agree that WYSO has implemented various safety measures intended to protect my child and others, but that when my child is participating in the WYSO programs and events, there are inherent risks of physical injury and illness, including the risk of exposure to or contracting the coronavirus/COVID-19 or other infectious diseases, and potential additional and associated consequences or costs. I acknowledge that my child’s participation in WYSO is completely voluntary, and as a condition of participation in WYSO, I agree that we (my child, and we as parents and guardians) will comply with all WYSO rules and requirements, including health screening and temperature checks as deemed appropriate by WYSO or through any other legal requirement or agency guidance. All information provided by screening will be kept confidential as required by applicable laws. WYSO will use the information provided only to advise and protect other students and staff members from any transmission of the virus.
Parent/Guardian Signature
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Section III: Release of Liability
I, the undersigned parent or legal guardian, authorize the above-named student (the “Student”) to participate in the Wisconsin Youth Symphony Orchestras (“WYSO”). I agree to hold harmless and release from liability WYSO and their respective directors, officers, employees, agents and volunteers (collectively, the “Released Parties”) relating to any action, proceeding, claim or damage that may arise as a result of the Student’s participation in WYSO, including (but not limited to) physical, emotional, or mental injuries. I understand that although the Released Parties may be present at performances and other WYSO activities (the “Activities”), the Released Parties will not be responsible for supervision of the Student. I am solely responsible for supervising the Student in connection with the Activities. I and the Student shall comply with all applicable laws in connection with the Activities, including all laws concerning alcohol and minors. I understand that the Activities may take place at various locations within the United States. I agree that I am solely responsible for the transportation of the Student in connection with the Activities and for all risks associated with travel, regardless of whether the Released Parties arrange transportation in connection with the Activities. I understand that the Activities may include performance opportunities and that the Student will come into contact with professional musicians, stage hands, sound engineers, audience members and others in connection with the Activities who are not under the control of the Released Parties. I understand and assume all risks associated with the Activities, and I agree to hold harmless and release from liability the Released Parties for any injuries in connection with the Activities (other than any injuries caused by the gross negligence or willful misconduct of the Released Parties).
Parent/Guardian Signature
*
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Section IV: Media Release
Throughout the 2022-2023 concert season, musicians may be highlighted in efforts to promote the Wisconsin Youth Symphony Orchestras (WYSO) activities and achievements. For example, musicians may be featured in grant applications and/or increase public awareness of WYSO through newspapers, radio, TV, the web, DVDs, displays, brochures and other types of media. I, as the parent or guardian of the minor listed below, hereby give WYSO and its employees, representatives and authorized media organizations permission to print, photograph and record my child for use in audio, video, film, or any other electronic, digital and printed media (via my electronic signature on this section). This is with the understanding that neither WYSO nor its representatives will reproduce said photograph, interview or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation. I further release and relieve WYSO, its Board of Directors, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material. I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions.
Media Release-Please Select One
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I give my consent to WYSO, in relation to the media release detailed above.
I DO NOT give my consent to WYSO, in relation to the media release detailed above. Please DO NOT photograph or record my child in any way that would make them individually identifiable.
Social Media Release - Please Select One
I give my consent to WYSO, in relation to the media release detailed above, to use my student’s image or video recording on social media.
I DO NOT give my consent to WYSO, in relation to the media release detailed above, to use my student’s image or video recording on social media. Please DO NOT photograph or record my child in any way that would make them individually identifiable.
Parent/Guardian Signature
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WYSO Code of Conduct
As a member of the Wisconsin Youth Symphony Orchestras, I am an “ambassador” for the entire organization; my behavior reflects upon the entire group. I am expected to use good manners, display common courtesy and show consideration for others. I understand that a successful WYSO experience requires a cohesive group wherein each individual accepts and follows the same standards of behavior. WYSO is dedicated to educating a diverse and changing student body. WYSO affirms its commitment to a community in which all students and staff are accepted and judged as individuals, independent of ancestry, social background, race, gender, disability, sexual orientation, physical characteristics, or personal beliefs. WYSO is a guest of multiple locations including, MCDS, McFarland HS, and other concert venues. It is a privilege for us to use these locations each week. Members will respect and follow the rules laid out by each venue.
Signature of Student
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Clear
Signature of Parent/Guardian
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Clear
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