Medical Form – Portland Summer Ensembles

"*" indicates required fields

Student Information

Student's Name*

First Last

Preferred Name

Age*

Date of Birth*

Address*

Street Address City State ZIP Code

Immunization Information

When was your child last immunized for Tetanus?*

(Date should be within the last 10 years)

Has your child had Chicken Pox?*

Yes

Has he/she had the Varicella vaccine?

Yes

Has your child been fully vaccinated with the COVID-19 vaccine?*

Yes

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COVID-19 Vaccine Documentation (optional)

I will upload my student's record now.

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Vaccine Record Upload

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 64 MB.

Please upload a copy of your child's COVID-19 vaccine card or record.

Please mail or deliver a copy of your child's COVID-19 vaccine record to Portland Summer Ensembles c/o MYS 4800 S Macadam Ave, Ste 105 Portland, OR 97239

Current medications

Please list all of them

Chronic illnesses or conditions

Please list all of them

Allergies

PSE Lunch Options/Dietary Restrictions*

Portland Summer Ensembles will provide lunch for enrolled students. Please let us know if you have any dietary restrictions or food allergies, select as many as are applicable. Select "Other" if you would like to provide an expanded description. Let us know if you plan to provide your own lunch instead.

Dietary Restrictions or Allergies Description

Any other medical or personal information of which PSE should be aware?

Family Physician*

Physician's Phone Number*

Insurance Provider

Insurance Group Number

Insurance ID Number

Employer

Employer connected to the insurance coverage.

Emergency Contact Person 1

In case of an emergency, PSE will notify the Emergency Contact Person 1. Please list 2nd & 3rd emergency contacts as well, non-family members if possible.

Emergency Contact Name*

First Last

Cell Phone*

Home Phone*

Work Phone*

Relationship to Musician*

Emergency Contact Person 2

Emergency Contact Name*

First Last

Cell Phone*

Home Phone*

Work Phone*

Relationship to Musician*

Emergency Contact Person 3

Emergency Contact Name

First Last

Cell Phone

Home Phone

Work Phone

Relationship to Musician

Terms and Conditions

Consent to Medical Care*

I accept the below terms and conditions (call MYS office with questions).

I do NOT accept the below terms and conditions

As parent or guardian of the musician, in the event of a medical emergency in my absence, I authorize PSE/MYS to obtain medical care for the musician, including consent to administration of drugs or anesthesia, medical procedures, evaluation and treatment. I agree to indemnify PSE/MYS for any medical expense incurred by PSE/MYS in connection with the musician, whether or not it is reimbursed by my insurance.

Email Address for Confirmation*

Your email address to confirm the completion of this form.

Name

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