Medical Form Step 1 of 5 20% Student InformationStudent's Name* First Last Age* Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 Has your child been fully vaccinated with the COVID-19 vaccine?* Yes No HiddenCOVID-19 Vaccine Documentation (optional) I will upload my student's record now. HiddenVaccine Record UploadAccepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 512 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 97239Current medicationsPlease list all of themChronic illnesses or conditionsPlease list all of themAllergies 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.NoneVegetarianVeganGluten FreeDairy FreeFood Allergies (please describe below)Other (please describe)No lunch - My student will bring a sack lunch from home each day.Dietary Restrictions or Allergies DescriptionAny 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 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 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.EmailThis field is for validation purposes and should be left unchanged.
