Hamilton Philharmonic Youth Orchestra 2015-16
Parental/Guardian Medical Consent Form- Canterbury Retreat October 3, 2015
Musician Name:
Father:
Work/Cell Phone:
Mother:
Work/Cell Phone:
OHIP Number:
OHIP Expiry:
Physician:
Phone:
Special Diet?
Special Diet Type:
Allergies:
Allergy Severity:
Allergy Type:
Other concern:
Medical Consent
I hereby give my consent to the treatment of minor medical problems by the chaperones of the
Hamilton Philharmonic Youth Orchestra with the understanding a physician will be called if necessary.
In the case of an emergency, I hereby consent to have the above named musician treated by an
attending physician.
Travel Consent
I hereby give my consent for the above named musician to participate in the planned activities at the
annual Canterbury Hills Orchestra Retreat aturday October 3, 2015. I also agree that the Hamilton
Philharmonic Youth Orchestra, Members of the Board of Directors, Coaches and
Chaperones cannot be held responsible for loss or damage to the above named musician's musical
instruments. It is the responsibility of the Parent/Guardian to have their ward's instruments insured
against loss or damage.
Signature of Parent
_____________________________
Date:
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