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

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