2024 Symphony Tour Medical Form Student Name* First Last Student Date of Birth* MM slash DD slash YYYY Student Cell Phone*It's crucial to enter the student's cell phone in this field, not a parent's phone number. This will be the method of contacting a student if needed during the tour.Has this student traveled internationally in the past 5 years?* Yes No The following information is required to ensure the health and well-being of GTCYS students during the tour, and will be kept confidential among GTCYS tour staff and chaperones.. Please be thorough: failure to disclose complete information compromises your student and GTCYS’ ability to care for them. GTCYS reserves the right to reevaluate a student’s participation in the tour if a student’s mental health or physical circumstances are beyond what can be practically supported abroad. Date of Last Tetanus Shot (Tdap)* MM slash DD slash YYYY Within the last 12 months, has this student been treated by a physician, psychiatrist, psychologist, therapist, counselor, social worker or other professional for any social, emotional, or mental health concerns (including, but not limited to: behavior adjustment, mood, eating, alcohol, drug, emotional or mental health concern of any kind)?** Yes No Details regarding treatment*Provide context and details about the above treatment, so GTCYS is fully informed about what the student needs to succeed on tour. Developmental conditions:*Does this student have any developmental conditions, learning disabilities, attention deficit disorders, and/or autism spectrum or neurordiverse conditions? Yes No Describe these conditions:*Please describe details about how developmental conditions, learning disabilities, attention deficit disorders, and/or autism spectrum or neurodiverse details present in this student. Next, share all information pertaining to treatments and coping mechanisms that this student needs to regulate these conditions.Does this student have any physical impairments (including, but not limited to, hearing or sight)?* Yes No Physical impairment or condition details and treatments:*Please describe details about physical impairments here, as well as any treatments and coping mechanisms (i.e. glasses, hearing aids, wrist braces, etc.)Has this student ever suffered an injury related to performing and practicing their instrument (such as tendinitis?)* Yes No Describe music-related injuries:*Describe the triggers for the injuries and any tools and treatment this student used or uses to manage and/or prevent recurrence.Does this student have asthma?* Yes No List triggers & treatment for asthma here:*Please include triggers such as exercise, strong emotions/stress, respiratory infections/common cold, cold air temperature, smoke, allergens, any other known triggers, and details about this student's treatment plan.Allergies:*Does this student have any allergies, including but not limited to medications, environmental allergies (pollen/animal dander/insect bites), food allergies or intolerances (i.e. shellfish, eggs, gluten, nuts, etc.), or other allergies not listed? Yes No Describe allergy and/or intolerances, the typical reaction(s), and typical treatment:*Does this student have anxiety?* Yes No Describe anxiety triggers and treatments/tools for coping here:*Describe triggers for this student's anxiety, such as crowds, strong emotions/stress, music performance, etc.) Describe the symptoms of this student's anxiety, such as fatigue, irritability, trouble sleeping, etc.). Share information about how this student is coping with anxiety, and what the student needs to succeed on tour.Mental health conditions:*Does this student have any mental health conditions, such as depression, bipolar disorder, OCD, eating disorder, or other not listed? Yes No Please describe mental health conditions here:*Please provide details such as triggers and explain how this condition presents in the student. Then, please explain the support, treatment, and coping plan that this student uses to regulate these conditions so GTCYS can support this student on tour.Significant life events:*Has this student experienced a significant life event that continues to affect their life, such as a family change like divorce, death of a loved one, history of abuse or trauma, etc.? Yes No Significant life events here:*Describe any significant life events and include details about any helpful support and coping techniques.Please describe any other physical, social, emotional, or health concerns not already listed above.*Please be detailed and specific and include any health history not already described above, such as diabetes, MS, Crohn’s, motion sickness, migraines or strong headaches, painful menstrual cycles, addiction, drug or alcohol use, mood disorders, sleep disorders, etc., as well as the recommended treatment plan to mitigate and regulate these conditions so GTCYS understands what students need to be successful on tour. Type "none" to complete the field if this student has no additional information to report. List tools for coping with stress:List some tools/mechanisms this student uses to cope with stress. The tour will be a life-changing experience, but being away from home, coping with jet lag, and following a rigorous schedule in a large group setting can also cause stress. The more information you can provide, the more GTCYS can understand what students need to be successful. Is this student currently prescribed any medications?*If you select "yes," complete as many medication names and purposes as needed below. Yes No List Medication 1 name and purpose:List Medication 2 name and purpose:List Medication 3 name and purpose:List Medication 4 name and purpose:List Medication 5 name and purpose:List Medication 6 name and purpose:List all other medication names and purposes:Parent/Emergency Contact InformationParent/Guardian #1 Name:* First Last Parent/Guardian #1 Cell Phone:*Does this student have another parent/guardian?* Yes No Parent/Guardian #2 Name:* First Last Parent/Guardian #2 Cell Phone:*Name of Emergency Contact if parents/guardians cannot be reached:* First Last Relationship to student:*Emergency Contact Cell Phone:*Primary Care Provider's Name:* First Last Primary Medical Care Provider’s Clinic Phone Number:*Health Insurance Carrier:*Policy/Group#*Additional information to support this student:Enter any other context or contacts which will aid GTCYS in supporting this student in a successful tour, i.e. therapist/psychologist/psychiatrist names and contacts and any additional background information regarding past traumas, triggers, and systems of support for this student. Parent/Guardian Medical ConsentPlease check the following boxes to acknowledge your agreement to these statements:* I acknowledge that the information provided in this form is complete, accurate, and truthful. * I understand that there may be times when illness or accident may occur, requiring immediate medical attention, and that it may not be possible to contact me immediately. * I give my general consent to the administration of minor first aid to the student to deal with matters of comfort or convenience and not requiring the attendance of medical personnel (e.g. cleaning a minor cut or scrape, providing over the counter medicine, etc.). * In the event of an emergency, I authorize GTCYS to make arrangements for qualified medical and surgical care for my child/ward without my prior approval. I understand that I will be notified by the quickest means possible if this authority is exercised. I also agree to accept financial responsibility for charges in excess of those covered by my health insurance. To indicate your signature, please enter your name and relationship to the student (for example Jane Smith, parent):*