Child's Name *

First Name

Last Name

Date of Birth *

Your child must be at least 6 years of age at the time of registration

MM

DD

YYYY

Parent/Guardian 1 *

First Name

Last Name

Main Phone *

(###)

###

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Secondary Phone

(###)

###

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Parent/Guardian 2

First Name

Last Name

Main Phone

(###)

###

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Secondary Phone

(###)

###

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Emergency Contact

If not listed above

First Name

Last Name

Phone

(###)

###

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Emergency Care *

In case of emergency if parent or guardian cannot be reached, I hereby grant permission to the local Emergency Department to provide urgent medical treatment for my child.

Being the lawful parent/guardian of the child named above hereby agree to indemnify the Hamilton Youth Steel Orchestra, its Board of Directors, its staff and its programme personnel, and save them harmless from all suits, actions or prosecutions by reason of any action or omission occurring during participation in the activities of the Hamilton Youth Steel Orchestra.

I certify that I have read and understood the information detailed in this application and that the information I have given and released is true and correct.

Do you give HYSO permission to use your child/children’s photo in HYSO publication and other advertisement items? *

You can change your decision any time with written consent to program managers, Karen Nelson and/or Cathy Ferreira

Yes

No