Medical Form – Portland Summer Ensembles

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
- No
Has he/she had the Varicella vaccine?
- Yes
- No
Current medications
Please list all of them
Chronic illnesses or conditions
Please list all of them
Allergies
Any other medical or personal information of which MYS should be aware?

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 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.
Name
This field is for validation purposes and should be left unchanged.

Student Information