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Medical Authorization Form

  • PERSONAL INFORMATION

  • This form is best filled out on a desktop/laptop.

    To save this form and return at a later time, scroll to the bottom of the page and click “Save and Continue Later."

  • All information on this form will be considered confidential. Withholding or falsifying information will absolve the University of Rochester of any responsibility should complications result. This form is the only medical record that will be on file for the student.
  • Federal guidelines mandate that we collect data on the legal sex of all applicants. If you would like the opportunity, you may also share more about your gender identity here:
  • MEDICAL HISTORY

  • If the answer is yes to either of the previous questions, please provide a letter from the student’s physician or counselor/therapist. You may upload the letter using our secure online dropbox or email the Summer@Eastman Office at summer@esm.rochester.edu

    Such information will be considered confidential and privileged.

    If there is anything in your religious beliefs that should be given consideration in the treatment of the student’s health or in case of an emergency, please provide a note of explanation.You may upload the letter using our secure online dropbox or email the Summer@Eastman Office at summer@esm.rochester.edu

    If your student will be requesting reasonable accommodations on the basis of a disability (for housing arrangements, classroom needs, or both), please visit: https://summer.esm.rochester.edu/accessibility-and-acommodations/

  • MEDICATION

  • MEDICATION POLICY

  • All medications must come in separate original labeled containers. Medications must not expire before the end of the session. Prescription medications must be written in the name of the student. All medication (prescription or non-prescription) must be accompanied by a patient-specific written order from a licensed prescriber. Pharmacy labeling on the medication is not sufficient for this purpose as the medication, dosage, and or regimen may have been changed since the pharmacy filled the prescription. This is a NY State requirement.

    If the student will need prescription refills during the program, please arrange to have the refills sent via delivery, as there are no pharmacies within walking distance of the Eastman campus.

  • RESTRICTIONS/ ALLERGIES

  • Allergies to:
  • IMMUNIZATIONS

  • New York State requires the following immunizations. Please specify the most recent date of immunization for each.
  • If not immunized for Meningococcus, my signature below certifies that I have read and understand the information on the website at www.esm.rochester.edu/summer/meningococcus and vaccination is declined at this time.
  • COVID-19 VACCINATION INFORMATION

  • All Summer@ Eastman participants must be fully vaccinated against the COVID-19 virus (2nd dose of Pfizer, Moderna or 1st dose of J&J/Janssen vaccines). As of April 6, 2022, booster shots are no longer required. Please select the type of vaccine(s) you have received and indicate the dates for each dose:
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  • You should have uploaded your COVID-19 vaccine card with your registration. If you would like to update your vaccine information, you may use our secure uploader to submit new vaccination documents.
  • Please upload photos or scans of the front and back of your vaccination card. Label the files with your name. If you are attending Summer Classical Studies, Summer Jazz Studies, Adventure Music Camp, High School Wind Ensemble, Keyboard Explorations, Gamelan Workshop, Music Educators Wind Ensemble, Music Educators Jazz Ensemble, or the Adult Chamber Music Workshop, please include “ECMS” in the file title:
    Example file name (ECMS programs in list above): ECMS_Last Name_First Name.jpg
    Example file name (all other programs): Last Name_First Name.jpg

    Questions? Email us at summer@esm.rochester.edu

    Submit COVID-19 Vaccination Proof to Summer@Eastman:

  • Once your upload is complete, please check below to confirm:
  • AUTHORIZATIONS

  • I consent to authorize the University of Rochester to refer my child for consultation to any licensed medical specialist as judged necessary and give authority and power to any such physician or surgeon to render any and all such diagnostic procedures, examinations, care, or treatment that he/she may deem necessary or advisable. Parents will be charged for all medical care, dental work, prescriptions, antibiotics, glasses, x-rays, consultations, and transportation required for such appointments. Eastman School of Music faculty or staff may accompany the student as circumstances warrant, and is authorized by the University of Rochester to sign proper permits.
  • In case of serious accident or illness involving my child while he/she is in the custody of the Eastman School of Music or its employees every effort will be made to contact parent or guardian. A situation may arise when emergency treatment may be necessary and the parent cannot be reached. In such situations, I authorize University of Rochester personnel to make provisions for treatment with the appropriate medical personnel or facility.
  • Answers to the questions above are valuable to health care while participating in Summer@Eastman. Questions must be answered fully and correctly. The Eastman School of Music reserves the right to dismiss any student or to cancel any contact if incorrect information is supplied on this form. I certify that all the answers I have given on this Medical Record form are complete and accurate to the best of my knowledge.
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Save and Continue Later

S@E Quick Links

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CONTACT US

Summer@Eastman Office
Eastman School of Music
26 Gibbs Street, Box 36
Rochester, NY 14604

585-274-1074
Email Us

Office Hours

Office Hours:

Monday-Friday: 9:00 AM - 3:00 PM

Saturday: Closed

Sunday: Closed

Saturday & Sunday: Closed

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