Tour Medical and Traveler Information Form | Metropolitan Youth Symphony

Traveler's Information

Traveler's Name*

First Last

Type of Traveler*

MYS Student
Alumni (adult)
Chaperone
Traveling family member (adult)
Traveling family member (child)

TSA Pre-check # (optional)

Global Entry # (optional)

Air Canada or United Frequent Flyer # (optional)

We will be flying Air Canada on the tour, if you have a frequent flyer number you would like to use, please enter it here. United MileagePlus members can also earn miles on Air Canada flights. Please indicate which airline your mileage # is for.

T-Shirt Size*

Adult sizes

T-Shirt Size

Age*

Date of Birth*

Address*

Street Address City State ZIP Code

Immunization Information

When was this traveler last immunized for Tetanus?*

(Date should be within the last 10 years)

Has this traveler had Chicken Pox?*

Yes
No

Has he/she/they had the Varicella vaccine?

Yes
No

Current medications*

Please list all of them or write N/A

Chronic illnesses or conditions*

Please list all of them or write N/A

Allergies*

Please list all of them or write N/A

Dietary Restrictions*

Participants will be provided breakfast and dinner on the tour (lunches will be independent at local restaurants). Please let us know if you have any dietary restrictions or food allergies, select as many as are applicable. Select "Other" if you would like to provide an expanded description.

Dietary Restriction or Allergy Description

Any other medical or personal information of which MYS should be aware?*

Please list all of them or write N/A

Family Physician*

Physician's Phone Number*

Insurance Provider*

Insurance Group Number*

Insurance ID Number*

Employer*

Employer connected to the insurance coverage.

Terms and Conditions

Consent to Medical Care (MYS Students or minor travelers)*

I accept the below terms and conditions (call MYS office with questions).
I do NOT accept the below terms and conditions

As parent or guardian of the musician/traveler, in the event of a medical emergency in my absence, I authorize MYS to obtain medical care for the musician/traveler, including consent to administration of drugs or anesthesia, medical procedures, evaluation and treatment. I agree to indemnify MYS for any medical expense incurred by MYS in connection with the musician/traveler, whether or not it is reimbursed by my insurance.

Consent to Medical Care (Adult travelers)*

I accept the below terms and conditions (call MYS office with questions).
I do NOT accept the below terms and conditions

In the event of a medical emergency, I authorize MYS to obtain medical care for myself, including consent to administration of drugs or anesthesia, medical procedures, evaluation and treatment. I agree to indemnify MYS for any medical expense incurred by MYS whether or not it is reimbursed by my insurance.

Email Address for Confirmation*

Your email address to confirm the completion of this form.

Comments

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