2021 - 2022 Vibe Medical Release Information
Please complete the following for your dancer's Medical Release information. This information will be kept in a secure location (non-public), and will only be made available to VPC/FootNotes staff and/or the Vibe medical bag volunteer (Dr. or nurse volunteer role).
Please select your Vibe group: *
Dancer First & Last Name *
Date of Birth *
MM
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DD
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YYYY
Home Address *
Parent Names *
Mom's Cell # (Please use format: xxx-xxx-xxxx) *
Dad's Cell # (Please use format: xxx-xxx-xxxx) *
Dancer's Cell #, if applicable (Please use format: xxx-xxx-xxxx)
Additional Phone Contact # and Name Optional (Please use format: xxx-xxx-xxxx)
Emergency Contact (other than parent) - Contact 1 Name & Relationship *
Emergency Contact - Contact 1 Cell # (Please use format: xxx-xxx-xxxx) *
Emergency Contact (other than parent) - Contact 2 Name & Relationship *
Emergency Contact - Contact 2 Cell # (Please use format: xxx-xxx-xxxx) *
Health Insurance Information
Insurance Company Name *
Insurance Company Phone # *
Insurance Company Policy Number *
Insurance Company Group # *
Insurance Company Policy Holder Name *
Name and Phone # of Family Physician *
Medical History
Date of Dancer's Last Health Exam *
Immunization up-to-date? YES/NO *
Chronic Illnesses or Injuries (check on any that apply) *
Required
Any history of concussion? Yes/No *
If Concussion = YES, note date and describe extent of injury. If Concussion = NO, then type in N/A. *
Any restrictions of physical activities? (Write N/A if not applicable) *
Any orthopedic issues? (Write N/A if not applicable) *
Any history of surgeries or fractures, or if recent injury, explain details? (Write N/A if not applicable, or if applicable, list details of surgery and/or fracture) *
Any history of allergies to medication? (Write N/A if not applicable, or if applicable, list all allergies, reaction type, symptoms, and treatment plan in case of exposure to allergen or allergic reaction) *
Any history of allergies to latex? (Write N/A if not applicable, or if applicable, list all allergies, reaction type, symptoms, and treatment plan in case of exposure to allergen or allergic reaction) *
Any history of allergies to food? (Write N/A if not applicable, or if applicable, list all allergies, reaction type, symptoms, and treatment plan in case of exposure to allergen or allergic reaction) *
List all current medications taken and/or routinely? Include dosage information. (Write N/A if not applicable.) *
If Epi-Pen or inhaler is used, can dancer self-administer? *
Medication that may be administered to dancer by adult in charge of activity. (Check all that apply) *
Required
Any other medical or health-related information that you would like to share? (Write N/A if no other information to share.) *
Medical Treatment Release
The health history is complete and accurate. I know of no reason(s), other than the information indicated on this form, why my child should not participate in prescribed activities except as noted. If this information changes during the VIBE performance year, I will notify the leaders in writing. I understand this information will remain confidential to the VIBE directors, adults in charge of girls at workshops, competitions and other activities and to designated persons trained in first aid and emergency personnel as needed. I hereby give permission to the adult in charge to provide routine health care, administer prescribed medications and seek emergency treatment including ordering x-rays and routine tests. I agree to the release of any medical records necessary for insurance purposes. I give permission to the adult in charge to arrange necessary related transportation for my child. Every effort will be made to contact parents and/or emergency contacts prior to treatment.
Parent or Legal Guardian Name *
Signature of Parent or Legal Guardian (type name in again to confirm) *
Please type "YES" to consent to allow your dancer's private medical information to be reviewed by parents who are medical professionals in the dance company and/or FootNotes staff who may need to refer to it during competitions and other events. *
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