Florida Show Choir Intensive – Emergency Medical Form
This form collects essential medical and emergency information for students, educators, and staff attending FSCI. Please fill out all required fields accurately.
Full Legal Name
*
First Name
Last Name
Preferred Name
Role at Camp
*
Please Select
Student
Educator
Staff
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
School or Organization
Hometown - City & State
*
Email Address
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Emergency Contact Name
*
Relationship to Participant
*
Please Select
Parent
Guardian
Spouse
Sibling
Friend
Other
Primary Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact Name
Relationship to Participant (Secondary)
Secondary Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have an adult supervisor or chaperone attending the camp with you?
*
Yes
No
Supervisor/Chaperone Full Name
First Name
Last Name
Supervisor/Chaperone Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any allergies?
*
Yes
No
List all known allergies (food, medication, environmental)
Describe the severity of your reaction(s) and treatment protocol
Do you carry an EpiPen or emergency medication for allergic reactions?
Yes
No
Please describe when and how it should be administered
Do you have any dietary restrictions or special needs?
*
Yes
No
Please specify (e.g., vegetarian, vegan, gluten-free, lactose intolerant, religious restrictions, etc.)
Are you currently taking any prescription or over-the-counter medications?
*
Yes
No
List all current medications, including dosage and frequency
Are any medications required during camp hours?
Yes
No
Please explain how and when these medications should be administered, and whether you will self-administer or need assistance
Do you have any chronic medical conditions (e.g., asthma, diabetes, epilepsy, heart conditions, anxiety, etc.)?
*
Yes
No
Please describe the condition(s), typical symptoms, and any accommodations or precautions needed.
Do you have any recent injuries, surgeries, or physical limitations that may affect participation in camp activities?
*
Yes
No
Please describe and include any necessary restrictions or modifications.
Health Insurance Provider
Policy Number
Group Number
Primary Physician Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital or Medical Facility
I authorize the Florida Show Choir Intensive (FSCI) staff, medical personnel, or designated representatives to obtain emergency medical care for myself (if an adult) or for my child (if a minor) in the event of illness or injury during participation.
*
I agree
I understand that reasonable efforts will be made to contact the emergency contact listed above before treatment is administered, when possible.
*
I agree
I assume full financial responsibility for any medical care provided as a result of emergency treatment.
*
I agree
Please include any other health information that FSCI staff should be aware of to ensure your safety and well-being.
Participant Signature
*
Parent/Guardian Signature (if participant is under 18)
*
Date Signed
*
-
Month
-
Day
Year
Date
PRIVACY STATEMENT: All medical information submitted through this form is kept strictly confidential and is shared only with authorized FSCI administrative and health/safety staff for emergency preparedness. Information is securely stored and used solely to ensure the well-being of all participants during the event.
*
Submit Medical & Emergency Information
Submit Medical & Emergency Information
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