Jazz Academy of Music
Medical Form

Health and Medical Information

The Maryland Department of Health and Human Services requires that all camp participants complete an emergency medical form. Each student must have one of these forms on file with the Jazz Academy. You must complete the form online or bring it with you on the first day of camp. Failure to do so could result in lost time as we may be forced by the Health Department to temporarily dismiss students who do not have a form on file.
For a hard-copy of the Medical Form and Medication Form if the student will need to take medication(s), including the use of an epi-pen, please request the PDF forms from the office by calling 301-871-8418 or emailing coordinator@jazzacademy.org
Thank you.

MEDICAL INFORMATION FORM DUE SUNDAY, 6/1/2025 BY MIDNIGHT!

ADULT AND LEGAL GUARDIANS ONLY:

  • Please fill out the following electronic medical form to provide confidential medical information for each student attending a JAM program

  • Student Information

  • Parent and/or Legal Guardian Information

  • COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION

    In the event of an emergency, when parents or emergency contacts cannot be reached, the Jazz Academy of Music will forward the information to emergency technicians and the student will be transported to the nearest hospital.
  • ANY MEDICATION, INCLUDING OVER THE COUNTER, REQUIRES A MEDICATION FORM FOR EACH MEDICATION. https://www.jazzacademy.org/jam-stage/medication-form-2/
  • If you have answered affirmatively to any of the questions above in this Medical Portion, please insure that the Jazz Academy Office has a current "MEDICATION FORM" on file.

  • AUTHORIZATION FOR CONSENT

  • EMERGENCY CONTACT(S)

    If I/We, the parents/guardians, cannot be reached in an emergency, please call:

  • PHYSICIAN/HEALTHCARE PROVIDER

  • INSURANCE

  • THANK YOU!!

  • THIS ELECTRONIC FORM WILL BE STORED AT THE JAZZ ACADEMY OF MUSIC OFFICE!
    JAM requires that all
    students attending camps or participating in field trips have this information on file.
    ALL INFORMATION IS CONSIDERED PERSONAL AND CONFIDENTIAL!
    LOCATION:
    JAM, PO Box 6744, Silver Spring, MD 20916-6744
    E-mail: coordinator@jazzacademy.org
    Phone Numbers:
    Office: 301-871-8418
    Paul Carr's Cell: 240-351-5329
    Karmen Carr's Cell: 240-353-4779