Medical Form

Medical Form Submission

* Indicates required field

Student's Name *

First

Last

Parent/Guardian #1 *

Parent/Guardian #1 Phone Number *

Parent/Guardian #2 *

Parent/Guardian #2 Phone Number *

Email *

Significant Medical Issues, please explain *

Allergies *

I hereby give permission to MLB School of Dance staff to administer first aid/CPR, call for transport and/or provide transport to the hospital for my child in the event of medical emergency *

Yes No

Immunization Records *

I will upload my Immunization Records I am exempt

Upload Immunization Records *

Max file size: 20MB

Sign & Date Here: *

Submit