Youth Programming Medical Form - Lyme Academy of Fine Arts

STUDENT INFORMATION

Student Name *

First

Middle

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email *

GUARDIAN/EMERGENCY CONTACT INFORMATION

Please submit any temporary guardianship documents to the Program Coordinator in advance of the workshop.

Full Name of Parent/Guardian *

First

Last

Relationship

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

MEDICAL INFORMATION

Every student needs a Medical Exam submitted to complete registration. These are valid for three years. If you need a form, click here to download.

Submit Medical Exam here

Click or drag a file to this area to upload.

Name of Student's Primary Care Physician

Phone Number

Name of Preferred Hospital

Phone Number

Allergies? If so, please specify:

Does the student need an Authorization for the Administration of Medication? (An authorized prescriber must sign off on any medications including Motrin, Tylenol, etc.)

Yes
No

Download Medication Administration Record (MAR) and Authorization Form here.

I have voluntarily provided the above contact information and authorize the Lyme Academy and its representatives to contact any of the above on my behalf in the event of an emergency.
I agree to the Terms and Conditions

Print Your Name and Phone Number

Date

Parent/Guardian Signature (leave blank – to be signed at the start of the program.)

Youth Program Registration Form

STUDENT INFORMATION

GUARDIAN/EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

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84 Lyme Street | Old Lyme, CT 06371
860.434.5232