Date Submitted
March 4, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Ethan Price
First
Ethan
Last
Price
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
XS
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
Keyboard
List Other Instrument and/or Multiple instruments here:
Number of Years of Formal Music Training
6
Previous Training in Jazz Improvisation
No
Have you been previously enrolled to the JAM Camp?
No
If yes, what year did you enroll to the Camp?
School
School's Name
Milton Gottesman Jewish Day School
City
Washington
State
DC
Grade Entering in Fall 2026
7
Student's Home Information
8037 Ellingson Drive
Chevy chase
State
MD
Zip
20815
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Rebecca Anhang Price
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Matthew Price
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Tracy Weeks
Contact 1 Relationship
Friend
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?
No
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
Date Submitted
March 3, 2026
Which program are you registering for?
Choose One
Student Name
Tomรกs Spitzberg
First
Tomรกs
Last
Spitzberg
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
S
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
AltoSax
List Other Instrument and/or Multiple instruments here:
Flute
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
Rosa Parks MS
City
Olney
State
MD
Grade Entering in Fall 2026
9
Student's Home Information
1 Stoneyhurst Court
Olney
State
MD
Zip
20832
Phone
Parent and/or Guardian Declaration
Parent 1 Name
David Spitzberg
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Mariana Spitzberg
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
David Spitzberg
Contact 1 Relationship
Father
Contact 2 Name
Mariana Spitzberg
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?
Yes
Survey Question
How did you hear about the JAM Camps?
Teacher
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
Date Submitted
March 2, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Felix Lekas
First
Felix
Last
Lekas
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
Trumpet
List Other Instrument and/or Multiple instruments here:
Number of Years of Formal Music Training
4
Previous Training in Jazz Improvisation
No
Have you been previously enrolled to the JAM Camp?
No
If yes, what year did you enroll to the Camp?
School
School's Name
Thomas Pyle Middle School
City
Bethesda
State
MD
Grade Entering in Fall 2026
8
Student's Home Information
5412 Glenwood Road
Bethesda
State
MD
Zip
20817
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Rebecca Trent
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Paul Lekas
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Deanna Lizas
Contact 1 Relationship
Aunt
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?
No
Survey Question
How did you hear about the JAM Camps?
Teacher
Note other source, including teacher here:
Alison Jacobs (Pyle)
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
February 21, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Simon Marshall
First
Simon
Last
Marshall
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:
Percussion
Number of Years of Formal Music Training
5
Previous Training in Jazz Improvisation
Yes
Have you been previously enrolled to the JAM Camp?
If yes, what year did you enroll to the Camp?
School
School's Name
Watkins Mill High School
City
Gaithersburg
State
MD
Grade Entering in Fall 2026
10
Student's Home Information
9313 Emory Grove Road
Gaithersburg
State
MD
Zip
20877
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Barbara Kaldi Marshall
Parent 1
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Nicholas Marshall
Additional Email Addresses
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Nancy Claggette
Contact 1 Relationship
Neighbor
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?
Choose One
Survey Question
How did you hear about the JAM Camps?
Teacher
Note other source, including teacher here:
This will be Simon's second year at JAM. We heard about it from a school flyer last year
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
February 20, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
August Fogle
First
August
Last
Fogle
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
Adult T-shirt Size
Email hidden; Javascript is required.
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
0
Previous Training in Jazz Improvisation
No
Have you been previously enrolled to the JAM Camp?
If yes, what year did you enroll to the Camp?
School
School's Name
Julius West Middle School
City
Rockville
State
MD
Grade Entering in Fall 2026
7 (fall of 2026)
Student's Home Information
604 Harrington Road
Rockville
State
Maryland
Zip
20852
Phone
Parent and/or Guardian Declaration
Parent 1 Name
Parent 1
Email hidden; Javascript is required.
Parent's Email Address (Primary)(valid email required)
Email hidden; Javascript is required.
Parent 2 Name
Additional Email Addresses
Email hidden; Javascript is required.
Parent's Daytime Phone
Additional Phone
Emergency Contacts
Contact 1 Name
Sam Yerkes
Contact 1 Relationship
neighbor
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?
No
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
