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JUST IN CASE WE NEED IT

Emergency Care Form

EMERGENCY CARE FORM

We want to take care of you as best we can. On the form please give us any information that we would need to make your journey with us a pleasant one. Should you need emergency services, we need permission from your parents/guardians on how to do so.

Also, please tell us any food or drug allergies which you have as well as any dietary needs.

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Scroll down to fill out the form.

EMERGENCY CARE FORM

Use this form to give us information needed for emergencies and pertinent information.

Date of birth
Month
Day
Year

Passport information

Are a citizen of the US?
Yes
No
Sex (on Passport)

Medical Information

Have you been hospitalized in the last 12 months?
No
Yes
Are you taking any prescription medication? If yes please provide the reason for the medication below.
No
Yes
Do you have allergies or reactions to medicines
No
Yes
Do you have any special health concerns? (EPI pen, etc)
No
Yes
Special Dietary Requirements

Emergency Contact

Alcohol Policy

Depending on local law, VaAM participants have an opportunity to partake in one glass of beer/wine at the evening meal in the presence of VaAM staff.
I do authorize my child to have beer/wine
I do not authorize my child to have beer/wine
I am an adult

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MEDICAL RELEASE

I, the undersigned, grant authorization for emergency medical treatment for my child or myself to the Virginia Ambassadors of Music and/or its staff or agents. It is understood that Virginia Ambassadors of Music will attempt to reach me or my emergency contact. In the event that I am not available, the tour director or his agent has my permission to use his/her discretion in securing emergency medical aid. It is further understood that neither Virginia Ambassadors of Music nor the person responsible for obtaining medical aid will be responsible for any expense incurred, nor will Virginia Ambassadors of Music or their staff nor representatives be held responsible for any medical condition that results from the aforementioned medical services.

Date
Month
Day
Year
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