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GENERAL INFORMATION
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MEDICAL RELEASE FORM
Name of Student
Date Of Birth:
Gender
Male
Female
Health Card Number
Travel Medical Insurance Company
Travel Medical Insurance Policy Number
Allergies (if applicable)
Dietary And/Or Health Restrictions (if applicable)
Medications Currently Taking & Instructions For Use (if applicable)
Recent Illness Or Medical Condition (if applicable):
Restrictions On Physical Activities (if applicable):
EMERGENCY CONTACT INFORMATION
Parent / Guardian 1:
First Name
Last Name
Home Phone
Cellular (Mobile) Phone
Parent / Guardian 2:
First Name
Last Name
Home Phone
Cellular (Mobile) Phone
Parent / Guardian 3:
First Name
Last Name
Home Phone
Cellular (Mobile) Phone
I give permission for my son/daughter to join Vancouver Island Music Academy in Brentwood College School, Mill Bay, BC, Canada from August 1 - August 16, 2024. I give permission to the Academy Staff to authorize medical treatment for my son/daughter in case of emergency.
Yes
No
Name Sign
Name and signature of parent or guardian
