Medical Form

Hi!

MUSIC VIDEO  MEDICAL FORM

PLEASE APPLY:

NAME: …………………………………………………………

ADDRESS:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

DATE OF BIRTH (MONTH/DAY/YEAR): …../…../…..

AGE: …………

SEX: M/F (circle when applicable)

UNDER 18 SECTION

IF UNDER 18: Childs name

…………………………………………………………………

HOME TELEPHONE: ……………………. 

MOBILE TELEPHONE/WORK: ……………………….

NAME OF GUARDIAN/PARENT: ……………………..

RELATIONSHIP TO CHILD: ………………………..

CONTACT: ………………………

END OF SECTION

(still applicable if under 18)

Do you take any medication? YES/NO (Circle when applicable)

If yes, please state the medication and the reason for which you are required to take it: …………………………………………………………………………………………………………………………….

How often are you required to take the medication and at what dosage?

……………………………………………………………………………………………………………………………..

Do you have any allergies and/or any Special Requirements? YES/NO (Circle when applicable) 

If yes, please state the allergies or special requirements:

……………………………………………………………………………………………………………………………

(IF OVER 18) I agree to look after and manage my medication personally and to take it if and when needed. In an emergency situation, I give permission for another  casting team member to give medicine. 

SIGNED: …………………………………………………………………..

DATE: ……………………………………………………………………….

(IF UNDER 18) I agree for my son/daughter participating in the music video “The Pursuit of Happiness” to take personal care of their medication and to take it when they know is needed. In an emergency situation, I allow a member of the casting team to give my child the medication.

SIGNED: ………………………………………………………………….

DATE:……………………………………………………………………. 

Thanks!