2014 Summer Academy of Music
Medical Information Form (Confidential)
Name: ________________________________________________________ Date: ___________________
Social Security Number: _____________________________________
The following information may help you in the unlikely even of an accident. Please complete this form as
accurately and truthfully as possible. Please read it through carefully before filling it out. The facts that you
disclose will only be used to help staff prevent or respond to an injury.
Gender: M or F
Age: ______ Birthdate: _________
Height: ________ Weight: _________
Address: ________________________________ City, State, Zip: ________________________________
Home Phone: _(___ )____________________ School: _______________________________________
In Case of Emergency, please contact:
Name: __________________________________Relationship:___________________________________
Address: ________________________________City, State, Zip: _________________________________
Home Phone: _(___)_______________________Work/Day Phone: _(___)_________________________
Doctor’s Name: __________________________ Phone: _(____)_________________________________
Medical Insurance Company: _____________________________________________________________
Policy Number: __________________________ Name of Policy Holder: __________________________
Please list and describe all information regarding the following:
Allergies: _____________________________________________________________________________
Disabilities: ___________________________________________________________________________
Heart Condition(s): _____________________________________________________________________
Phobia(s) or Fear(s): ____________________________________________________________________
Past Injuries or Illnesses: _________________________________________________________________
Past Operation(s): ______________________________________________________________________
Current Medication(s): ___________________________________________________________________
Date of Most Recent Tetanus Booster: _______________________________________________________
Are you allergic to bee stings? Y or N
If yes, do you carry medicine? Y or N
Signature of person completing this form: ___________________________________________________