Century Symphonic Strings Orchestra
Student Health Form
The purpose of this form is for us to know about conditions that may arise while in New York.
Name: Birthdate: / / Gender: M / F
Address: Home Phone #:
City: Zip Code: ______
Emergency Contact (name): Emergency #: ______
Check any of the following health condition(s) your child has:
1. ADD/ADHD 14. Infections-frequent/severe
2. Allergies 15. Kidney/Bladder conditions
3. Anaphylactic (life threatening) reaction 16. Learning problems
4. Asthma 17. Lung/Breathing problems
5. Dental/Orthodontic problems 18. Orthopedic conditions
6. Diabetes 19. Pain/Discomfort-frequent/severe
7. Ear/Hearing problems 20. Permanent or long-term disability
8. Eye/Vision problems 21. Serious accidents
9. Emotional/Behavioral problems 22. Seizures/Convulsions
10. Food Restrictions/Special diet 23. Stomach/Intestinal/Abdominal conditions
11. Headaches-frequent/severe 24. Weight concerns
12. Heart/cardiovascular conditions 25. Motion Sickness
13. Hospitalizations (major)/surgery 26. Other
For any conditions checked above, please specify by number the current status, treatment, medication, care, and history. Use the back of this form if necessary.
Does child wear glasses/contacts? Y N Are they to be worn at all times? Y N
Does child have any activity restrictions? Y N Specify:
Is child taking any medications not listed above? Y N Specify:
Has child had Chickenpox? Y N Has child had a skin test for tuberculosis? Y N
Any additional information you care to share:
The information provided on this sheet is for emergency use only! The information may be shared with medical/care providing staff if necessary. Information will be used only if your child needs treatment.
I understand that the information provided is correct and accurate. Also, this information may be used in the treatment of while on the Century Symphonic Strings Orchestra to New York. (Student name)
Please list any other information that you may want the chaperones to know about your student:
Parents: Please sign on the line noted below.
Parent/Guardian Name
Home Phone: Work:
Cell Phone:
My Health/Accident Policy is with:
The Address is:
Policy Holder Name:
This Policy Does/Does Not cover my Child (Name):
Medical Information
Please list ANY medical problems such as allergies, chronic symptoms, or dietary needs in the space below.
RELEASE AND WAIVER OF LIABILITY/IMPLIED CONSENT FORM.
In signing this form, I understand that I waive the right to sue teachers, chaperones, school administrators, the school board of district 535, Leisure Time Tours, or any group or individual associated with it, for me and my heirs, assigns, or personal representatives.
I hereby give permission for the chaperones to provide any medical assistance they feel appropriate for my child named above. I also give permission for medical personnel to treat my child in the event of an emergency. I will be responsible for any and all medical expenses incurred.
I am aware that the chaperones of the Century Symphonic Strings Orchestra trip may require or mandate activities, which may involve participation by my child. I wish my child to participate in these trips, and I acknowledge that during those trips, my child may be exposed to certain risks which are inherent in the activity and cannot be eliminated without destroying the unique character of the activity, such as travel by bus boat, monorail, swimming, accidents or illness in areas with limited medical facilities, and the forces of nature, including the sun, wind and rain. I understand that the description of these risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death.
In consideration of the right to participate in these activities, and the services arranged for me, for myself and my child, I have and do hereby assume all risks and will forever indemnify, hold harmless, and covenant not to sue teachers, chaperons, school administrators, the school board of District 535, Leisure Time Tours, and member from any and all liability, actions, causes of action, debts, claims, demands or other liability of every kind and nature whatsoever which may arise from or in connection with my child’s trip or participation in any activities, whether caused by ordinary negligence or otherwise. This signed agreement shall serve as a release or assumption of risks for my heirs, executor, and administrators, assigns, next of kin and for members of my family. This agreement is meant to be as broad and inclusive as allowed under the State of Minnesota and the State of Florida. If any portions of this release are found invalid, the balance shall remain in full legal force and effect. I give permission for staff members to take photos or videos of my child participating in these activities, which will remain the property of the school and chaperones, Leisure Time Tours to be used in promotion. I have read and fully understand this agreement.
Signature of Parent/Guardian Date:
Parental Permission Form
All students on field trips with the Rochester Public School District and Teachers from this district are required to follow a strict set of guidelines relating to the use of inappropriate and illegal substances. These include alcohol, tobacco, and drugs other than prescription, regardless of whether the student is over 18 years of age. Since we will be so far away from home as a group it is essential that all students follow guidelines relating to the timing and location of other members of the group and not leave the group for any reason whatsoever.
In the event that the student does not follow these guidelines or is discovered with or under the influence of illegal substances, the following will occur. The student will be driven to the nearest airport and /or bus station and will buy a ticket, at the parent’s expense, for the next flight (or slow bus) to Rochester, Minnesota. The Parents will be contacted and informed of the time of the arriving flight.
Thank you for your understanding and compliance.
Sincerely,
Julianne Dahlin
I agree to abide by the rules set forth by the sponsor of this Century Panther Orchestra New York Tour.
X Date: ______
(Student signature)
X Date: ______
(Parent/Guardian Signature)