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Student Medical Condition with Medical Intervention Form

Studio Medical Form for New Season

IMPORTANT NOTICE: The studio requires a NEW MEDICAL FORM to be signed for EVERY STUDENT enrolled at the start of each new season. Health matters and changes in status can happen suddenly, so we ask that you update the studio staff with any changes regarding your child's health.

We appreciate your prompt communication as the well-being of all our students is ALWAYS a top priority! 

Please provide information about any medical conditions or allergies your child currently has. This information will help our instructors and staff provide the best care while at the studio.



 

 


First Parent/Guardian Name

First Name*

Middle Name

Last Name*

Phone*
First Parent/Guardian Date of Birth*
First Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

First Parent/Guardian Signature*
Second Parent/Guardian Name

First Name*

Middle Name

Last Name*
Second Parent/Guardian Date of Birth*
Second Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Third Parent/Guardian Name

First Name*

Middle Name

Last Name*
Third Parent/Guardian Date of Birth*
Third Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Fourth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Fourth Parent/Guardian Date of Birth*
Fourth Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Fifth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Fifth Parent/Guardian Date of Birth*
Fifth Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Sixth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Sixth Parent/Guardian Date of Birth*
Sixth Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Seventh Parent/Guardian Name

First Name*

Middle Name

Last Name*
Seventh Parent/Guardian Date of Birth*
Seventh Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Eighth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Eighth Parent/Guardian Date of Birth*
Eighth Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Ninth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Ninth Parent/Guardian Date of Birth*
Ninth Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Tenth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Tenth Parent/Guardian Date of Birth*
Tenth Parent/Guardian please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's please fill out below for your child/student:

Student Name (First/Last) *

Student Date of Birth *
Does your child have any medical conditions, allergies, or physical limitations? If an adult student-do you have any medical conditions, allergies or physical limitations?*
No
Yes, please describe in the provided box below

Student Allergy/Medical Condition:
Will your child need to bring any medical intervention or medication with them to class or events? If an adult student- will you need to bring any medical intervention or medication along with you to class or events?*
No
Yes, please decribe in box provided below

What Emergency Medical Intervention is Needed (EPI Pen, Inhaler, Insulin)

Do you give Step 1 Dance 2 Academy Staff permission to aid your child with the specified intervention in an emergency situation? *

By signing below, you are granting permission to allow the studio staff and/or instructors to use any necessary interventions in the event of a medical situation related to you/your child's condition while they are under the studio’s care. This may include, but is not limited to, assisting with the administration of medications or providing immediate care for allergies, physical impairments, or any other medical conditions as necessary.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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