Name: ___________________________________ Birth Date: _____________ Nickname: ______________
Emergency Contact/Relation: _________________________________ Number: ________________________
Emergency Contact/Relation: _________________________________ Number: ________________________
Physician: _________________________________________________ Number: ________________________
Eye Doctor _______________________________________________ Number: ________________________
Dentist: __________________________________________________ Number: ________________________
Other: ___________________________________________________ Number: ________________________
Health Insurance: ___________________________________________ Number: ________________________
Group Number: __________________________________ Agreement Number: _________________________
Current Medical Condition:
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
4. ________________________________________________________________________________________
Allergies (Foods, medications, etc.)
1. ________________________________________ 4. ___________________________________________
2. ________________________________________ 5. ___________________________________________
3. ________________________________________ 6. ___________________________________________

Procedures to avoid:
1. ________________________________________ 3. ___________________________________________
2. ________________________________________ 4. ___________________________________________
Activity Restrictions:
1. ________________________________________ 3. ___________________________________________
2. ________________________________________ 4. ___________________________________________
Prescription and non-prescription medications currently being taking and purpose of each:
1. ________________________________________ 4. ___________________________________________
2. ________________________________________ 5. ___________________________________________
3. ________________________________________ 6. ___________________________________________
Does Student Self-Medicate?: ________________ Date of Last Tetanus Shot: ______________________
Comments on student or other specific medical issues:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
The University of Montana does not provide medical insurance or other medical facilities or services for the participants in the UM School of Theatre & Dance BRAVO! After-School Acting classes. To assure that medical treatment may be made available to participants in a timely manner, should the need arise, the University requests that the below treatment authorization be signed by the appropriate parent or guardian.
Treatment Authorization Statement: I hereby authorize any licensed medical doctor of the Missoula medical community to administer to my ( circle one ) son/daughter/ward any appropriate medical treatment services which may be necessary to assure physical health and well-being during the period of his/her stay at the University of
Montana during BRAVO! After-School Acting classes. It is fully understood and agreed that I shall be responsible for payment of any expense incurred for medical attention and the University of Montana or doctor shall make a sincere effort to contact me to obtain verbal authorization prior to relying on this written authorization.
Signature: ________________________________________________ Date: _________________________
(Mother, Father or Legal Guardian)