Medical Form Step 1 of 5 20% Student InformationStudent's Name* First Last Age*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Immunization InformationWhen was your child last immunized for Tetanus?*(Date should be within the last 10 years)Has your child had Chicken Pox?*YesNoHas he/she had the Varicella vaccine?YesNoCurrent medicationsPlease list all of themChronic illnesses or conditionsPlease list all of themAllergiesAny other medical or personal information of which MYS should be aware? Family Physician*Physician's Phone Number*Insurance ProviderInsurance Group NumberInsurance ID NumberEmployerEmployer connected to the insurance coverage. Emergency Contact Person 1In 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 2Emergency Contact Name* First Last Cell Phone*Home Phone*Work Phone*Relationship to Musician*Emergency Contact Person 3Emergency Contact Name First Last Cell PhoneHome PhoneWork PhoneRelationship to Musician Terms and ConditionsConsent to Medical Care*I accept the below terms and conditions (call MYS office with questions).I do NOT accept the below terms and conditionsAs parent or guardian of the musician, in the event of a medical emergency in my absence, I authorize 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 MYS for any medical expense incurred by 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.NameThis field is for validation purposes and should be left unchanged.