Medical Form Step 1 of 5 20% Musician's InformationMusician's Name* First Last Age*Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* 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 My child has received one dose of a COVID-19 vaccine This field is hidden when viewing the formVaccine Received Pfizer - 2 doses Moderna - 2 doses Johnson and Johnson This field is hidden when viewing the formPlease upload student's COVID-19 vaccine record (optional) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB, Max. files: 1. This field is hidden when viewing the formHard Copy of COVID-19 Vaccine I will deliver a hard copy of my child's COVID-19 vaccine record to the MYS office Current 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, MYS 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 PhoneWork PhoneRelationship to Musician*Emergency Contact Person 2Emergency Contact Name* First Last Cell Phone*Home PhoneWork PhoneRelationship 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.PhoneThis field is for validation purposes and should be left unchanged.
