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Trip Permission Form

The Greater Westchester Youth Orchestras Association
Spring Gala Concert
Avery Fisher Hall - May 1, 2011

Please return this form by April 25, 2011


I give permission for my child, _________________________ , to participate in the above-mentioned trip, as a parent or guardian, and on behalf of my child, I authorize in the event of an accident, injury or illness of my child arising out of the participation in this trip, first aid or emergency medical treatment as may be deemed necessary or desirable by the person or persons in charge of the program or activity. Further, I release the Greater Westchester Youth Orchestras Association, Inc. and its Division and their respective officers and directors, employees, conductors, members or agents from any and all liability for any acts or omissions out of or in connection with my child’s participation in this trip.

In the event that my child causes any bodily injury or property damage by his/her negligence, I agree to indemnify and hold harmless the Association, its officers and agents from any expense or loss arising out of such negligence

Date____________________ Parent /Guardian ___________________________

Telephone numbers where you can be reached:

__________________________________________________________

Name of persons and telephone number to contact in emergency if you are not reachable:

__________________________________________________________

Name, address, and telephone number of child’s physician:

__________________________________________________________

Health Insurance carrier and ID No.

__________________________________________________________

Any information (such as allergies to certain medicines, etc.) that you feel will be helpful to us or to any attending physician:

__________________________________________________________