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Date Submitted
February 16, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Ashr Gauri
First
Ashr
Last
Gauri
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
AltoSax
List Other Instrument and/or Multiple instruments here:
Guitar
Number of Years of Formal Music Training
5-6
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
Walt Whitman HS
City
Bethesda
State
MD
Grade Entering in Fall 2026
9
Student's Home Information
5309 Burling Ter
Bethesda
State
MD
Zip
20814
Parent and/or Guardian Declaration
Parent 1 Name
Parent 1
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
(202) 441-3651
Additional Phone
(240) 938-4234
Emergency Contacts
Contact 1 Name
Mona Khan
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?
Choose One
Survey Question
How did you hear about the JAM Camps?
Teacher
Note other source, including teacher here:

Allison Jacobs

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 16, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Luke Burgess
First
Luke
Last
Burgess
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
TenorSax
List Other Instrument and/or Multiple instruments here:
Sax Alto
Number of Years of Formal Music Training
9
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
Walt Whitman High School
City
Bethesda
State
MD
Grade Entering in Fall 2026
9
Student's Home Information
5708 Glenwood Road
Bethesda
State
MD
Zip
20817
Parent and/or Guardian Declaration
Parent 1 Name
Parent 1
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
(917) 499-4947
Additional Phone
(202) 710-6364
Emergency Contacts
Contact 1 Name
Sarah Zetterli
Contact 1 Relationship
Friend
Contact 2 Name
Federica Tourreilles
Contact 2 Relationship
Fried
Contact 2 Phone (Camp Hours)
(202) 256-8199
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:

Luke plays alto sax for the Jazz Academy!

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 14, 2026
Which program are you registering for?
JAM Extended Day 9am - 5pm (6/29-7/10)
Student Name
Mihir Nabar
First
Mihir
Last
Nabar
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
AltoSax
List Other Instrument and/or Multiple instruments here:
Tenor Sax, Flute, Piano, Clarinet
Number of Years of Formal Music Training
9 years
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
Walt Whitman High School
City
Bethesda
State
MD
Grade Entering in Fall 2026
9th
Student's Home Information
6214 Crathie Lane
Bethesda
State
MD
Zip
20816
Parent and/or Guardian Declaration
Parent 1 Name
Parent 1
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
(401) 527-2161
Additional Phone
(202) 631-8750
Emergency Contacts
Contact 1 Name
Alaka Holla
Contact 1 Relationship
Mother
Contact 2 Name
Malhar Nabar
Contact 2 Relationship
Father
Contact 2 Phone (Camp Hours)
(202) 631-8750
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:

Teacher

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 10, 2026
Which program are you registering for?
JAM Camp 1-5pm (6/29-7/10)
Student Name
Peter Bopp
First
Peter
Last
Bopp
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
Adult T-shirt Size
Instrument including Vocal and Training
Select your Instrument
AltoSax
List Other Instrument and/or Multiple instruments here:
Number of Years of Formal Music Training
1 full year and parts of 2 other years
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
Student's Home Information
314 West Edmonston Drive
Rockville
State
MD
Zip
20852
Parent and/or Guardian Declaration
Parent 1 Name
Parent 1
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
(301) 651-6543
Additional Phone
(310) 595-5428
Emergency Contacts
Contact 1 Name
Joan Cole
Contact 1 Relationship
Grandmother
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?
Other Electronic Media, include e-mail
Note other source, including teacher here:

A local parenting Facebook group

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 3, 2026
Which program are you registering for?
Choose One
Student Name
Peter Muller
First
Peter
Last
Muller
Student's Email Address
Email hidden; Javascript is required.
T-Shirt Size
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
2
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
Takoma Park Middle
City
Silver Spring
State
MD
Grade Entering in Fall 2026
8
Student's Home Information
508 Mississippi Ave
Silver Spring
State
MD
Zip
20910
Parent and/or Guardian Declaration
Parent 1 Name
Parent 1
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
(617) 901-3152
Additional Phone
(202) 230-9154
Emergency Contacts
Contact 1 Name
Alec Muller
Contact 1 Relationship
Uncle
Contact 2 Name
Beth Harris
Contact 2 Relationship
Neighbor
Contact 2 Phone (Camp Hours)
(120) 299-7708
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:

Previous student’s parent- Andrea Richter

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
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