2024/2025 JBS Health History & Medical Info

"*" indicates required fields

Are you enrolled as a*

Student's Name*

First Last

Address*

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

Date of Birth*

MM slash DD slash YYYY

Age*

Phone*

Pronouns*

Headshot*

Please upload student's headshot.

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 80 MB.

Parent/Guardian Information

Child is in the custodial care of:

Both Parents

Mother Only

Father Only

Other

If you selected Other, please describe

Parent/Guardian 1

First Last

Phone Number

Parent/Guardian 2

First Last

Phone Number

Emergency Contacts

Emergency Contact #1*

First Last

Relationship*

Phone Number*

Emergency Contact #2

First Last

Relationship

Phone Number

Allergy Information

Explain "yes" answers. Include the type of allergy (e.g. - "nut allergy" in the food category)

Insect Stings*

Yes

Explanation

Plants/Trees*

Yes

Explanation

Food*

Yes

Explanation

Medications*

Yes

Explanation

Other*

Yes

Explanation

Explain any specific needs or accommodations required:

Health History

Explain any behavior, emotional, or mental health concerns:

Explain any psychiatric counseling, hospitalization, or eating disorder treatment:

Explain any operations or serious injuries:

Explain any dietary modifications (vegetarian/vegan/lactose free, etc):

Immunization History

Are all immunizations current?*

Yes

If not, state reason(s):*

Tetanus Date:

MM slash DD slash YYYY

Medication Information

Are any prescription medications being taken?*

Yes

Are any any of the following being used?

EpiPen

Inhaler

Name of Medication 1:

Reason for Medication:

Dosage

Frequency

Name of Medication 2:

Reason for Medication:

Dosage

Frequency

Name of Medication 3:

Reason for Medication:

Dosage

Frequency

Insurance Information

Insurance Company*

Policy Number*

Policy Holder*

Company Address*

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

Insurance Provider's Phone Number*

Important Information

Students are required to establish a primary care physician in the New York City area. Contact your insurance provider to find the nearest physicians/doctors that are in-network with your insurance plan.

Students are required to establish a primary care physician in the Plano area. Contact your insurance provider to find the nearest physicians/doctors that are in-network with your insurance plan.

Physician*

Phone Number*

Address*

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

Authorization for Medical Care:

This health history is correct and complete so far as I know. I/We, the undersigned, parents/legal guardians of the student as named below (the "Minor", a minor, do hereby authorize the Joffrey Ballet School, (the "Agent"), on behalf of the undersigned, to consent to the surgical, dental and/or medical examinations or treatment of the Minor. Such treatment may include, but is not limited to, the following; transportation by ambulance, examination, x-rays and other diagnostic procedures, any diagnoses, hospitalization, anesthesia, surgery, medication, and or/transfusion of blood or blood products. Agent may have access to any and all records, including, but not limited to, insurance records regarding any such services. (Enter Student Name Below)*

Is it understood that this Authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but it is given to provide authorization and power on the part of our aforesaid Agent to give specific consent to any and all such diagnoses, treatment, or hospital care which the physician or other caregiver may in the exercise of his/her best judgement may deem advisable. Unless sooner terminated in writing, this Authorization shall be effective beginning on*

MM slash DD slash YYYY

and ending on*

MM slash DD slash YYYY

Release & Indemnification

I/We, the undersigned, parents/legal guardians of the Minor, shall indemnify, hold harmless, assume liability for, and defend the Agent and Joffrey Ballet School, Center for American Dance, Inc., their affiliated entities, its owners, directors, officers, employees, and agents from and against any and all liability for personal injury, damages, costs and/or expenses, including but not limited to attorney’s fees and costs, arising or resulting from the exercise of any powers granted under this Authorization.

Electronic Signature*

Date*

MM slash DD slash YYYY

CAPTCHA

"*" indicates required fields

Are you enrolled as a*

Student's Name*

First Last

Address*

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

Date of Birth*

MM slash DD slash YYYY

Age*

Phone*

Pronouns*

Headshot*

Please upload student’s headshot.

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 80 MB.

Parent/Guardian Information

Child is in the custodial care of:

Both Parents

Mother Only

Father Only

Other

If you selected Other, please describe

Parent/Guardian 1

First Last

Phone Number

Parent/Guardian 2

First Last

Phone Number

Emergency Contacts

Emergency Contact #1*

First Last

Relationship*

Phone Number*

Emergency Contact #2

First Last

Relationship

Phone Number

Allergy Information

Explain “yes” answers. Include the type of allergy (e.g. – “nut allergy” in the food category)

Insect Stings*

Yes

Explanation

Plants/Trees*

Yes

Explanation

Food*

Yes

Explanation

Medications*

Yes

Explanation

Other*

Yes

Explanation

Explain any specific needs or accommodations required:

Health History

Explain any behavior, emotional, or mental health concerns:

Explain any psychiatric counseling, hospitalization, or eating disorder treatment:

Explain any operations or serious injuries:

Explain any dietary modifications (vegetarian/vegan/lactose free, etc):

Immunization History

Are all immunizations current?*

Yes

If not, state reason(s):*

Tetanus Date:

MM slash DD slash YYYY

Medication Information

Are any prescription medications being taken?*

Yes

Are any any of the following being used?

EpiPen

Inhaler

Name of Medication 1:

Reason for Medication:

Dosage

Frequency

Name of Medication 2:

Reason for Medication:

Dosage

Frequency

Name of Medication 3:

Reason for Medication:

Dosage

Frequency

Insurance Information

Insurance Company*

Policy Number*

Policy Holder*

Company Address*

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

Insurance Provider's Phone Number*

Important Information

Students are required to establish a primary care physician in the Plano area. Contact your insurance provider to find the nearest physicians/doctors that are in-network with your insurance plan.

Physician*

Phone Number*

Address*

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

Authorization for Medical Care:

MM slash DD slash YYYY

and ending on*

MM slash DD slash YYYY

Release & Indemnification

Electronic Signature*

Date*

MM slash DD slash YYYY

CAPTCHA