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Student Information


Home Address


Guardian Information

Private Instruction

Do you take private lessons?

Band/Orchestra Director

Will you be enrolled in your school orchestra/band for the 2022-2023 school year?
Please share why:

Allergies/Medical Concerns

All medical information is confidential and will only be shared with qualified medical personnel in the event of an emergency.

Does the student have allergies to food, medication, insect bites, plants or anything else about which we should be informed?  Please describe below.
Does student have any history of medical/emotional problems (i.e. asthma, epilepsy, eating disorders, anxiety disorders, depression, etc.)?  Please describe below.
Does the student carry an inhaler or epi-pen at all times?  Please describe below.
Is there anything else you would like to speak to our staff about concerning your child?  Please describe below.


Is your child currently taking any medication?

If bringing medication(s) to LSYO, medication must be provided to LSYO staff on arrival. Medication must be labeled and placed in a zip lock bag. The student is responsible for locating LSYO staff to take medication.

Medical Release

I give permission for my child to receive medical and emergency care during LSYO and for a physician or other appropriate medical personnel to treat my child in a manner he/she thinks appropriate, in case of a medical emergency and/or a problem.  I authorize the chaperone (adult) to administer properly labeled over-the-counter medication that I may designate in writing.  Further, I permit my son/daughter to self-administer prescribed medications listed on this medical information form.  I agree that all medications shall be in original containers, and I waive the right to seek damages against the chaperone administering such medication.  I understand that I am responsible for the payment of all medical and emergency services rendered to my child.  I certify that the above information is complete and accurate to the best of my knowledge.  Misrepresented information or lack of information is grounds for immediate dismissal from LSYO. 

LSYO Policies

I have downloaded, read, and agree to the LSYO policies.  (Download it here.)

COVID Policy

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. By voluntarily attending in-person events, you agree to comply with all rules imposed by the CDC, federal, state, and local governments, the rules required at the premises of the event, if any, and the rules of Loudoun Symphony Association regarding conduct at the event related to COVID-19, and to conduct yourself in a reasonable and safe manner, in accordance with guidance from public health authorities.

By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.

Media Release

I authorize the Loudoun Symphony Youth Orchestra to allow videotaping/recording of all activities related to performances and rehearsals. The Loudoun Symphony Youth Orchestra has my consent to use video tapes/recordings or pictures of my child in rehearsals or performances for the purposes of training and teaching within the program as well as for promotional purposes for the Loudoun Symphony Youth Orchestra.


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