ASO Medical Permission

Please complete this form, print, notarize, and return it by December 18, 2015.  In addition to the form, a copy (front and back) of the medical insurance card is required.

Medical insurance for each student is required for participation in the Missouri All State Orchestra.

Please mail this medical form and copy of insurance card as well as a check to MoASTA for $125, the ASO Release, ASO Code of Conduct and band registration form (wind/percussion students only) in one mailing to:

Aimee Fine
MoASTA Secretary/Treasurer
808 Swift’s Hwy.
Jefferson City, MO 65109

Student first name
Student last name

has our permission to attend rehearsals and the performance of the 2015 Missouri All State Orchestra. MOASTA and MMEA assume no liability by virtue of the above named student's participation and attendance in the All State Organization at the MMEA Conference. If our son or daughter, whose name appears above, should require medical attention while at Tan Tar A, the person designated by MOASTA has our permission to take our child to a doctor, hospital, or any other medical institution for necessary medical treatment.

Parent/Guardian first name

Parent/Guardian last name

__________________________________________
Parent/Guardian signature

_____________________
Date signed

Please list any medications the student is currently taking:

Please list any allergic reaction(s) to any medication the above student may have:

Please list any other medical information you feel we should know about your child:

Please list the company that has medical insurance on your child:

Insurance Policy Number:

Please attach a copy of the medical card (front and back) to this form.

In case of emergency, please notify:

Contact #1:
First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone

Contact #2:
First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone

MoASTA, MMEA and/or Tan-Tar-A Resort assumes no responsibility for any loss or damages to musical instruments.

THIS FORM IS NOT VALID UNLESS THE NOTARY PORTION BELOW IS COMPLETED:

Subscribed and sworn to me the __________________ day of _______________, 2014.

_________________________________, Notary Public

My commission expires______________ Seal