Medical Form

← Back

Thank you for your response. ✨

Full Name

Month

Day

Year

Social Security Number

Emergency contact

Telephone 1

Telephone 2

Telephone 3

Emergency contact address

I have medical conditions for which I am under a doctor's care(required)

Yes

If yes, please state the condition and the associated doctor's name and contact information in each case

If you have any physical limitations which might need to be taken into consideration, please describe

If you are on a special diet or have food allergies, please describe

If you are allergic to bee stings or insect bites, please specify what medications you normally take

If you will be taking any medications while at Inspiration Point, please list below the names of the medicines and the schedule you will follow in taking them. You are encouraged to bring a plentiful supply as it may be difficult to fill a prescription should you run out.

Month

Day

Year

Name and contact info of your GP

Medical insurance policy information

Name of Participant

By checking this box and typing my name below, I am electronically signing this authorization

Signature:

Relationship to Participant

Youth Music Camps at Inspiration Point

Vocal, String, and Piano Camp

Medical Form

Thank you for your response. ✨