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.

Student Name*

First Last

Preferred Name/Nickname (if applicable)

Date of Birth*

Gender*

Gender Information (optional):

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:

Parent/Guardian responsible for medical bills*

First Last

Parent/Guardian Email*

Program(s) student is attending:

Primary doctor*

Doctor’s phone with area code*

Doctor's Address*

Street Address Address Line 2 City State/Province/Region ZIP/Postal Code Country

Medical Insurance Provider*

Policy Number*

MEDICAL HISTORY

Any medical conditions or allergies we should be aware of?*

Yes
No

If Yes, describe below:

Does the student need any special consideration on the advice of a physician?*

Yes
No

Does the student need any special consideration on the advice of a psychiatrist, psychologist, or mental health therapist?*

Yes
No

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 classroom needs), please visit: https://summer.esm.rochester.edu/accessibility-and-acommodations/

MEDICATION

Is the student on medication (prescription or over-the-counter)?*

Yes
No

Medication

Dosage

Condition treated

Additional information about medications can be entered here:

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.

RESTRICTIONS/ ALLERGIES

Any current restrictions on activity or diet?*

Yes
No

If Yes, list below:

Allergies to:

Food

Medications

Other

IMMUNIZATIONS

New York State requires the following immunizations. Please specify the most recent date of immunization for each.

Diphtheria:

Tetanus:

Polio:

Measles #1:

Measles #2

Mumps:

Haemophilus influenzae type B:

Rubella:

Hepatitis B

Varicella (chicken pox)/date of infection:

Meningococcus:

If the student has not received all immunizations, please explain the reason:

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.

AUTHORIZATIONS

CONSENT FOR MEDICAL CARE AND REFERRAL:*

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.

I agree.

SERIOUS ACCIDENT OR ILLNESS:*

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.

I agree.

PARENTS AND STUDENTS ACKNOWLEDGEMENT:*

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.

I agree.

Typed Signature of parent or guardian*

Date*

Typed Signature of student*

Date*

PERSONAL INFORMATION

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

MEDICAL HISTORY

MEDICATION

MEDICATION POLICY

RESTRICTIONS/ ALLERGIES

IMMUNIZATIONS

AUTHORIZATIONS

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