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Medical Release Form
2023 Cremona International Music Academies Medical Release Form
July 11 - July 28, 2023
Cremona, Italy
Please note: All fields marked with * (asterisks) are mandatory fields that must be filled out in order to process the form.
Student Information
Full Name of Student
*
Gender
*
Date of Birth
*
MM slash DD slash YYYY
Medical Information
Medical Insurance Company
*
Medical Insurance Policy Number
*
Allergies (If none, enter "None".)
*
Dietary and/or Health Restrictions (If none, enter "None".)
*
List any medication student is currently taking and instructions for use. (If none, enter "None".)
*
List any recent illness or medical condition. (If none, enter "None".)
*
List any restrictions on activities. (If none, enter "None".)
*
Additional Information (optional)
Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Alternate Phone
Emergency Contact Email
*
Emergency Contact Alternate Email
Release and Agreement
I give permission for my son/daughter to join Cremona International Music Academy in Cremona, July 10 - July 31, 2022. I give permission to the Academy Staff to authorize medical treatment for my son/daughter in case of emergency.
*
Yes
Parent/Guardian Signature
*
Date
*
MM slash DD slash YYYY