Medication Form

  • CONFIDENTIAL PRESCRIPTION AND OVER THE COUNTER MEDICATION FORM

    Please fill out the following electronic medical form to provide confidential medical information for each student attending a JAM program

  • Student Information

  • Medication

    Please use one online form per medication

  • Epi-pen | Inhaler

    Checking this box indicates that the medication is an epi-pen or inhaler that the student can carry and self administer

  • PHYSICIAN/PRESCRIBER

  • AUTHORIZATION FOR CONSENT

    In the event of an emergency, when parents or emergency contacts cannot be reached, The Jazz Academy of Music will forward the information to emergency technicians and the student will be transported to the nearest hospital.
  • Primary parent or legal guardian completing this form

  • THANK YOU!!