Brass Camp 2021 Medical Form
While your child will only be in our care for a brief period of time once a week, it is best that we are prepared for any medical emergency that may take place, and having a medical form on hand helps in case something were to happen.  All information will be reviewed by the director and kept private, only to be used in the event of an emergency.  If you questions or concerns regarding this, please contact Michael Buckstein at michaelbucksteinmusic@gmail.com
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Student Name *
Student Gender *
Student Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Name *
Home Address *
Parent/Guardian Cell Phone (Please list phone numbers in the following format with dashes: xxx-xxx-xxxx) *
Parent/Guardian Home Phone ((Please list phone numbers in the following format with dashes: xxx-xxx-xxxx) *
Parent/Guardian Alternate Phone (Please list phone numbers in the following format with dashes: xxx-xxx-xxxx) *
Alternative Emergency Contact Name *
Alternative Emergency Contact Relationship to Student *
Alternative Emergency Contact Cell Phone (Please list phone numbers in the following format with dashes: xxx-xxx-xxxx) *
Alternative Emergency Contact Home Phone (Please list phone numbers in the following format with dashes: xxx-xxx-xxxx) *
Alternative Emergency Contact Home Address *
Hospital Preference *
Physician's Name *
Physician's Phone Number (Please list phone numbers in the following format with dashes: xxx-xxx-xxxx) *
Drug/Environmental/Food Allergies *
Special Medical Conditions or Other Pertinent Information *
I give permission for my child to attend rehearsals/performances as required. I release the staff of Brass Camp from liability in case of accident during activities related to Brass Camp, as long as normal safety procedures have been taken. By signing electronically below, I (parent/guardian) acknowledge that I have read and understood all the information contained in this medical form. *
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