Medical Form Step 1 of 5 20% Student InformationStudent's Name* First Last Age* Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* 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?* Yes No Has he/she had the Varicella vaccine? Yes No Current medicationsPlease list all of themChronic illnesses or conditionsPlease list all of themAllergies Any other medical or personal information of which MYS 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 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 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.CommentsThis field is for validation purposes and should be left unchanged.
