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Student Medical Condition with Medical Intervention Form

The studio requires a NEW MEDICAL FORM to be signed on behalf of EVERY STUDENT ENROLLED IN EACH NEW SEASON.

Health matters and changes in status can happen suddenly, we ask that you update studio staff in every instance that involves a student .

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


In an effort to be well informed about EVERY student and any special care they may need due to a present Medical Condition/Allergy, we ask that parents disclose any physical limitations, ailments or impairments which may affect them while dancing at the Studio. In such a case, we ask for prior authorization to aid them with any necessary interventions. Please indicate below your child's specific allergy or medical condition, along with whether or not they will have any such interventions with them during the studio classes/events. 

By signing below, you are granting permission to allow the studio staff and/or instructors to use those methods if such a situation may occur while under their care.

 

 


First Student's Name

First Name*

Middle Name

Last Name*

Phone*
First Student's Date of Birth*
First Student's Information

Student Allergy/Medical Condition: *

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? *
First Student's Signature*
Second Student's Name

First Name*

Middle Name

Last Name*
Second Student's Date of Birth*
Second Student's Information

Student Allergy/Medical Condition: *

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? *
Third Student's Name

First Name*

Middle Name

Last Name*
Third Student's Date of Birth*
Third Student's Information

Student Allergy/Medical Condition: *

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? *
Fourth Student's Name

First Name*

Middle Name

Last Name*
Fourth Student's Date of Birth*
Fourth Student's Information

Student Allergy/Medical Condition: *

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? *
Fifth Student's Name

First Name*

Middle Name

Last Name*
Fifth Student's Date of Birth*
Fifth Student's Information

Student Allergy/Medical Condition: *

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? *
Sixth Student's Name

First Name*

Middle Name

Last Name*
Sixth Student's Date of Birth*
Sixth Student's Information

Student Allergy/Medical Condition: *

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? *
Seventh Student's Name

First Name*

Middle Name

Last Name*
Seventh Student's Date of Birth*
Seventh Student's Information

Student Allergy/Medical Condition: *

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? *
Eighth Student's Name

First Name*

Middle Name

Last Name*
Eighth Student's Date of Birth*
Eighth Student's Information

Student Allergy/Medical Condition: *

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? *
Ninth Student's Name

First Name*

Middle Name

Last Name*
Ninth Student's Date of Birth*
Ninth Student's Information

Student Allergy/Medical Condition: *

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? *
Tenth Student's Name

First Name*

Middle Name

Last Name*
Tenth Student's Date of Birth*
Tenth Student's Information

Student Allergy/Medical Condition: *

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? *
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 Information

Student Allergy/Medical Condition: *

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? *
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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