Singer Health & Emergency Form

A red asterisk (*) indicates required field.

Singer's Name:*
Name of Person Completing Form:*
Parent E-mail:*

SINGER HEALTH & EMERGENCY INFORMATION

Emergency Contact Name (to be called if neither parent can be reached):*
Emergency Contact Phone:*
-
Relationship to Singer:*
Medical Insurance:*
Parent Signature - By signing below (typing name), parent releases Portland Choirs from any responsibility for the cost of medical treatment or injury while participating in Portland Choirs events:*
Physician Name:
Clinic Name:
Patient ID #:
Patient Group #:
Physician/Clinic Phone:
-
Physician/Clinic Address:
Health in the past year:*
Current Health:*
Immunizations (check all that are current):
Has your child been diagnosed and/or treated for learning disabilities, including dyslexia, Asperger's Syndrome, Autism, and Attention Deficit Syndrome? Please list current treatments and medications:

Indicate YES or NO to all medications that you give permission to Portland Choirs Staff / Chaperone to administer to your child as needed.

Ibuprofen (Advil):
Acetaminophen (Tylenol):
Children's Ibuprofen (Children's Advil)
Children's Acetaminophen (Children's Tylenol):
Antacid (Tums or similar):
First Aid (including first air triple antibiotic ointment to help prevent infection in minor cuts, scrapes, and burns)
Sunscreen
Insect Repellent (OFF)
For any medication selected as "YES," please specify reasons to treat, dose amounts, and dose schedule:
ALLERGIES: List allergies, reactions, and medication(s) / treatment(s).
SERIOUS ILLNESS: List all past & current asthma, diabetes, epilepsy, etc., treatment, and date(s).
NIGHTTIME HABITS: List any that Portland Choirs should be aware of for overnight events, including sleep walking, recurring nightmares, bedwetting, seizures, etc.
ADDITIONAL INFORMATION: Provide additional information Portland Choirs and a physician should know about your child.

PERMISSION & RELEASE: The undersigned states and affirms that we are either the parents or legally authorized guardians of the above-named minor child. We give permission for our child to participate in activities and events sponsored by Portland Choirs, including summer music camp, retreats, workshops, and tours.

We hereby give the adult staff and chaperones of Portland Choirs permission to authorize medical treatment for our child as they deem necessary or reasonable after reasonable effort has been made to contact both parents and emergency contacts. We agree to assume responsibility for all costs associated with such medical care.

In return for Portland Choirs allowing our child to participate in rehearsals, performances, summer music camp, tours, retreats, workshops and other sponsored events, we agree to hold harmless and release Portland Choirs, its directors, officers, employees and agents from all actions, causes of action, damages, claims or demands which the undersigned or our child or any successor may have against Portland Choirs, or such parties for all personal injuries which may arise out of or relate in any way to activities of Portland Choirs.

We understand that participation in Portland Choirs activities is voluntary and at our election and choice and that Portland Choirs is a not-for-profit corporation and that its board of directors are volunteers and serve without compensation. The person signing below acknowledges having read this release and understanding all of its terms and their significance and states that this release is signed and delivered voluntarily.

This permission and release form will remain in effect until the above named child (1) no longer participates in Portland Choirs sponsored events, (2) until it is replaced with a more current form, or (3) until we notify Portland Choirs in writing of the withdrawal of our permission and release.

Acknowledge and sign by typing full name in box below.

Enter Parent(s) Name(s):*

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