Medication Form

In which program is the student attending?*

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

Student Information

Student Name*

Student T-Shirt Size*

Are you the parent and/or legal guardian?*

Yes

Parent Name*

First Last

Email Address*

Relationship to student?*

Day Phone*

Parent and/or Legal Guardian Information

Parent 1 [P1] and/or Father's Name

[P1] Phone #

[P1] Cell #

[P1] Email Address

Parent 2 [P2] and/or Mother's Name

[P2] Phone #

[P2] Cell #

[P2] Email Address

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.

Food allergies? (Please list.)

Drug, insect sting or other allergies? (Please list.)

Does the student require an Epi-pen?

Yes
No

When was the student's last tetanus, or DPT shot?

Has the student been fully immunized?

Yes
No

Is there a religious objection or medical contradiction why the student is not immunized?

Yes
No

Are there any physical conditions that would limit the students ability to participate in physical activities?

Yes
No

Is the student on any prescription or over the counter medication?

Yes
No

ANY MEDICATION, INCLUDING OVER THE COUNTER, REQUIRES A MEDICATION FORM FOR EACH MEDICATION. https://www.jazzacademy.org/jam-stage/medication-form-2/

Are there any conditions that the Jazz Academy of Music should be aware of, such as, Special Needs, ADHD, Asthma, OCD, Emotional Issues, Surgeries, Diseases, or Health Conditions?

Yes
No

If "YES" to question above please list condition(s):

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.

I do hereby verify that the student, to the best of my knowledge, is free from all and and contagious disease(s), is fully immunized and is able to participate fully in the JAM for which he/she is registered.

Yes
No

Has the student been fully immunized? (Select One)

Yes
No

EMERGENCY CONTACT(S)

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

Name*

Relationship*

Phone*

Name

Relationship

Phone

PHYSICIAN/HEALTHCARE PROVIDER

Doctor

Doctor's Phone #

INSURANCE

Insurance Company

Insurance thru (Policy Holder)

Policy Number

Group Number

AUTHORIZATION FOR CONSENT

By checking this box you are consenting to treatment should the student appear to be having a life-threatening, breathing or other emergency.

Agree

Student Information

Parent and/or Legal Guardian Information

COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION

EMERGENCY CONTACT(S)

PHYSICIAN/HEALTHCARE PROVIDER

INSURANCE

AUTHORIZATION FOR CONSENT

THANK YOU!!

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