University of Montana School of Music
BAND
2016 Summer Music Camps
CHOIR
Medical/Consent Form
STRINGS
PIANO
Camper Information
Name: ___________________________________ Birth Date: _____________ Nickname: ______________
Emergency Contact/Relation: _________________________________ Number: ________________________
Emergency Contact/Relation: _________________________________ Number: ________________________
Physicians
Physician: _________________________________________________ Number: ________________________
Eye Doctor _______________________________________________ Number: ________________________
Dentist: __________________________________________________ Number: ________________________
Other: ___________________________________________________ Number: ________________________
Insurance Information
Health Insurance: ___________________________________________ Number: ________________________
Group Number: __________________________________ Agreement Number: _________________________
Medical Information
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. ___________________________________________
List prescription and non-prescription medications you are taking and purpose:
1. ________________________________________
4. ___________________________________________
2. ________________________________________
5. ___________________________________________
3. ________________________________________
6. ___________________________________________
Does Camper Self-Medicate: ________________
Date of Last Tetanus Shot: ______________________
Comments on child or other specific medical issues:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Consent for Emergency Medical Treatment
The University of Montana does not provide medical insurance or other medical facilities or services for the
participants in the UM Summer Music Camp. To assure that medical treatment may be made available to
participants in a timely manner, should the need arise, the University requests that the treatment authorization
below 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 UM Summer Music Camp. 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)