Date Submitted
May 15, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Damon Jenkins
First
Damon
Last
Jenkins
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
M
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Trombone
List Other Instrument and/or Multiple instruments here:
Number of Years of Formal Music Training
6
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
Yes
If yes, what year did you enroll to the Camp?
2025
School
School's Name
Julius West Middle
City
Rockville
State
MD
Grade Entering in Fall 2026
7
Student's Home Information
2303 Rockland Ave
Rockville
State
MD
Zip
20851
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Tiffany Dickson
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Suzan Jenkins
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Willard Jenkins
Contact 1 Relationship
grandfather
Contact 2 Name
Donna Kleffman
Contact 2 Relationship
family
Contact 2 Phone (Camp Hours)
All information is True and Correct
- Yes
Yes
Payment Plan (Optional/Select Deposit on Tuition Page)
Available payment options
No
Are you interested in a private lesson?
Choose One
Survey Question
How did you hear about the JAM Camps?
Teacher
Note other source, including teacher here:
Paul Carr
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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] Email Address
[P2] Cell #
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
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.
EMERGENCY CONTACT(S)
Name
Relationship
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
EMERGENCY CONTACT(S)
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.
Ok
Date Submitted
May 5, 2026
Which program are you registering for?
Week 1 - JAM Camp 6/29-7/3
Student Name
Anders Carlsten
First
Anders
Last
Carlsten
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
L
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Drums
List Other Instrument and/or Multiple instruments here:
drums
Number of Years of Formal Music Training
7
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
Yes
If yes, what year did you enroll to the Camp?
2024
School
School's Name
Damascus High School
City
Damascus
State
MD
Grade Entering in Fall 2026
12
Student's Home Information
25460 Paine St
Damascus
State
MD
Zip
20872
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Britta Carlsten
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Additional Email Addresses
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Emily Tuck
Contact 1 Relationship
family friend
Contact 2 Name
John Koslowski
Contact 2 Relationship
Family Friend
Contact 2 Phone (Camp Hours)
All information is True and Correct
- Yes
Yes
Payment Plan (Optional/Select Deposit on Tuition Page)
Available payment options
No
Are you interested in a private lesson?
Yes
Survey Question
How did you hear about the JAM Camps?
Teacher
Note other source, including teacher here:
Dr Charles Doherty - years ago
In which program is the student attending?
Week 1 - JAM Camp 6/29-7/3
Student Information
Student Name
Anders Carlsten
Student T-Shirt Size
L
Are you the parent and/or legal guardian?
- Yes
Parent Name
Britta Carlsten
First
Last
Email Address
Email hidden; Javascript is required.
Relationship to student?
mother
Day Phone
Parent and/or Legal Guardian Information
Parent 1 [P1] and/or Father's Name
Britta Carlsten
[P1] Phone #
[P1] Cell #
[P1] Email Address
Email hidden; Javascript is required.
Parent 2 [P2] and/or Mother's Name
[P2] Phone #
[P2] Email Address
[P2] Cell #
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.)
mango
Drug, insect sting or other allergies? (Please list.)
no
Does the student require an Epi-pen?
No
When was the student's last tetanus, or DPT shot?
1/14/2020
Has the student been fully immunized?
Yes
Is there a religious objection or medical contradiction why the student is not immunized?
No
Are there any physical conditions that would limit the students ability to participate in physical activities?
No
Is the student on any prescription or over the counter medication?
No
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
If "YES" to question above please list condition(s):
ADHD
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
Has the student been fully immunized? (Select One)
Yes
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.
- Ok
EMERGENCY CONTACT(S)
If I/We, the parents/guardians, cannot be reached in
an emergency, please call:
Name
Emily Tuck
Relationship
Family Friend
Phone
Name
John Koslowski
Relationship
Family Friend
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Ariel Dubelman
Doctor's Phone #
INSURANCE
Insurance Company
Cigna
Insurance thru (Policy Holder)
Britta Carlsten
Policy Number
000051907 03
Group Number
3345160
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
EMERGENCY CONTACT(S)
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.
Ok
Date Submitted
May 4, 2026
Which program are you registering for?
JAM Extended Day 9am - 5pm (6/29-7/10)
Student Name
Adam Slagle
First
Adam
Last
Slagle
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
M
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Clarinet
List Other Instrument and/or Multiple instruments here:
Number of Years of Formal Music Training
7
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
Yes
If yes, what year did you enroll to the Camp?
2025
School
School's Name
BCC High School
City
Chevy Chase
State
MD
Grade Entering in Fall 2026
Freshman at UMD
Student's Home Information
5500 Kirkside Dr
Chevy Chase
State
MD
Zip
20815
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Tim Slagle
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Julia Matheson
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Tim Slagle
Contact 1 Relationship
Father
Contact 2 Name
Julia Matheson
Contact 2 Relationship
Mother
Contact 2 Phone (Camp Hours)
All information is True and Correct
- Yes
Yes
Payment Plan (Optional/Select Deposit on Tuition Page)
Available payment options
No
Are you interested in a private lesson?
No
Survey Question
How did you hear about the JAM Camps?
Family or Friend
Note other source, including teacher here:
Alex Moschovakis
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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] Email Address
[P2] Cell #
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
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.
EMERGENCY CONTACT(S)
Name
Relationship
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
EMERGENCY CONTACT(S)
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.
Ok
Date Submitted
April 29, 2026
Which program are you registering for?
JAM Extended Day 9am - 5pm (6/29-7/10)
Student Name
Talia Makris Fonda
First
Talia
Last
Makris Fonda
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
M
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Keyboard
List Other Instrument and/or Multiple instruments here:
tenor sax
Number of Years of Formal Music Training
5
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
Yes
If yes, what year did you enroll to the Camp?
2025
School
School's Name
cabin john middle
City
Potomac
State
MD
Grade Entering in Fall 2026
8th
Student's Home Information
10926 Bells Ridge DR
Potomac
State
MD
Zip
20854-2790
Phone
Parent and/or Guardian Declaration
Parent 1 Name
daren fonda
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
joanna makris
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
daren fonda
Contact 1 Relationship
dad
Contact 2 Name
joanna makris
Contact 2 Relationship
mom
Contact 2 Phone (Camp Hours)
All information is True and Correct
- Yes
Yes
Payment Plan (Optional/Select Deposit on Tuition Page)
Available payment options
No
Are you interested in a private lesson?
No
Survey Question
How did you hear about the JAM Camps?
Teacher
Note other source, including teacher here:
Paul Bratcher
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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] Email Address
[P2] Cell #
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
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.
EMERGENCY CONTACT(S)
Name
Relationship
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
EMERGENCY CONTACT(S)
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.
Ok
Date Submitted
April 27, 2026
Which program are you registering for?
JAM Extended Day 9am - 5pm (6/29-7/10)
Student Name
Adam Augusteijn
First
Adam
Last
Augusteijn
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
L
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Drums
List Other Instrument and/or Multiple instruments here:
Drums, piano (beginner)
Number of Years of Formal Music Training
6
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
Yes
If yes, what year did you enroll to the Camp?
2025
School
School's Name
Albert Einstein High School
City
Kensington
State
MD
Grade Entering in Fall 2026
Senior
Student's Home Information
3125 Homewood Parkway
Kensington
State
MD
Zip
20895
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Michael Augusteijn
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Sylvia Augusteijn
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Timothy Augusteijn
Contact 1 Relationship
Older brother
Contact 2 Name
Contact 2 Relationship
Contact 2 Phone (Camp Hours)
All information is True and Correct
- Yes
Yes
Payment Plan (Optional/Select Deposit on Tuition Page)
Available payment options
No
Are you interested in a private lesson?
Yes
Survey Question
How did you hear about the JAM Camps?
Family or Friend
Note other source, including teacher here:
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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] Email Address
[P2] Cell #
COMPLETE FORM IN ITS ENTIRETY MEDICAL PORTION
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
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.
EMERGENCY CONTACT(S)
Name
Relationship
Phone
Name
Relationship
Phone
PHYSICIAN/HEALTHCARE PROVIDER
Doctor
Doctor's Phone #
INSURANCE
Insurance Company
Insurance thru (Policy Holder)
Policy Number
Group Number
In which program is the student attending?
Student Information
Student Name
Student T-Shirt Size
Are you the parent and/or legal guardian?
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
Food allergies? (Please list.)
Drug, insect sting or other allergies? (Please list.)
Does the student require an Epi-pen?
When was the student's last tetanus, or DPT shot?
Has the student been fully immunized?
Is there a religious objection or medical contradiction why the student is not immunized?
Are there any physical conditions that would limit the students ability to participate in physical activities?
Is the student on any prescription or over the counter medication?
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?
If "YES" to question above please list condition(s):
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.
Has the student been fully immunized? (Select One)
EMERGENCY CONTACT(S)
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.
Ok
