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

Student Information