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Premier Orchestral Institute Summer Camp 2024 - Medical Form
All participants must complete this form by May 10th, 2024
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Email
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Your email
PARTICIPANT'S PERSONAL INFORMATION
Please ensure that the information provided in the next section is accurate and updated for the POI participant
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Female
Male
Clear selection
Address
Your answer
City
Your answer
State/Province
Your answer
Zip/Postal Code
Your answer
Country
Your answer
Phone Number
Your answer
Email Address
Your answer
EMERGENCY CONTACT INFORMATION
Please ensure that the information provided in the next section is accurate and updated for your emergency contact details
Name
Your answer
Relationship to Camper
Your answer
Phone Number
Your answer
Email Address
Your answer
PHYSICIAN'S CONTACT INFORMATION
Please ensure that the information provided in the next section is accurate and updated for your physician's contact information
Name
Your answer
Phone Number
Your answer
Address
Your answer
MEDICAL HISTORY
Please ensure that the information provided in the next section is accurate and updated for your medical history
Please list any chronic medical conditions
Your answer
Are there any allergies (food, medication, environmental)?
Option 1
Clear selection
List any current medications
Your answer
Have you had any surgeries or hospitalizations in the past year?
Option 1
Clear selection
Do you have any dietary restrictions? Be specific
Your answer
Are you up to date on vaccinations?
Yes
No
Clear selection
Have you ever experienced any of the following medical conditions? (Check all that apply)
Asthma
Diabetes
Epilepsy
Heart Disease
Hypertension
Mental Health Disorders
Other
If you selected 'other' in the previous question, please specify your condition
Your answer
Do you have any physical limitations or disabilities we should be aware of?
Your answer
Are you currently undergoing any medical treatment or therapy?
Your answer
Is there anything else we should know about your medical history?
Your answer
Authorization:
I hereby authorize the Premier Orchestral Institute Summer Camp medical staff to administer medical care and treatment as deemed necessary in the event of an emergency. I understand that every effort will be made to contact the emergency contact listed above prior to any treatment. I also certify that the information provided in this form is accurate and complete to the best of my knowledge.
Yes
Clear selection
Signature
Your answer
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