Summer Intensive Student Information Form

ICON Summer Intensive Student Information Form

Fill out this informational form in order for your student to attend summer intensives at ICON.

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Student Details

Student Name(Required)

First Last

Preferred name:(Required)

Student Pronouns(Required)

Student Email

Student Phone

Rising Grade Level (2025-26)(Required)

Student Birth Date(Required)

MM slash DD slash YYYY

Attendance and Participation

My student is attending (check all that apply):(Required)

June 9th Classical Dance

June 30th Contemporary Dance

June 16 Musical Theatre (Session 1)

June 30th Musical Theatre (Session 2)

June 30th Visual Arts (Session 2)

Housing status during ICON Summer Intensives:(Required)

Student Life Activity Fee(Required)

This fee will allow your student to participate in events and meals scheduled after day sessions are completed, as well as holidays and within-session weekend times.

Guardian and Emergency Contacts

Guardian Name(Required)

First Last

Guardian Email(Required)

Guardian Phone(Required)

Emergency Contact Name(Required)

First Last

Relationship to Student(Required)

Phone(Required)

Health Information

Student Dietary Restrictions and Allergies(Required)

Vegetarian

Vegan

Gluten Free

Gluten Sensitivity

Lactose Intolerant

Tree Nuts

Peanuts

None

Does your student adhere to a special diet or food preference? Please list and describe.

What over the counter medications is your student allowed to take while attending ICON summer intensives? Please check all that apply.(Required)

Ibuprofin

Tylenol

Sudafed

Motrin

Allergy/Flonase

Cough Syrup

None

Has your student begun menstruation?(Required)

Have they been taught about menstruation including using tampons, if allowed?(Required)

Does your student take any medications or have medical alerts the team should be aware of?(Required)

Please describe the medication schedule if it applies to your student. Include time of day and dosage.

Please note: any medications your student brings to summer intensives must be in their correct prescription bottle and may not be expired.

Does your student carry an Epi-Pen?(Required)

Please confirm you will provide two Epi-Pens for their stay at ICON.(Required)

Describe the reason your student carries an Epi-Pen:(Required)

Health Professional Contacts and Health History

Primary Care Provider Name(Required)

Primary Care Phone(Required)

Dentist Name(Required)

Dental Phone(Required)

Medical Insurance Card(Required)

Max. file size: 128 MB.

Immunization Records(Required)

Max. file size: 128 MB.

Date of Last Tetanus Shot:(Required)

MM slash DD slash YYYY

Medical Special Care – Please indicate any that apply:(Required)

Bedwetting

Asthma

ADD/ADHD

Bleeding/Clotting Issues

Cardiac Defect

Diabetes

Fainting

Frequent Bathroom Breaks

Hepatitis

HIV

Migraines

Seizure/Epilepsy

Sleepwalking

Not Applicable

Specialty Care Provider

Specialty Care Phone

Describe any past or current medical treatment:

Boarding Student Life Information

How is your student when it comes to taking care of personal belongings?

Does your student have any responsibilities in the home? Please describe:

Social-Emotional/Behavioral

Does your student have any behavioral conditions?

Has your student had problems with peers? If so, please explain:

Should your student be exempt from any activities while at ICON summer intensives?

Is there anything else you'd like us to know about your student?

Consent: Marketing(Required)

Marketing Acknowledgement: You understand that your child may be captured in media (i.e. photo) and this media may be used to promote future ICON events (that will use the name or image of your student)

Consent: Medical Authorization(Required)

If, in the opinion of a properly licensed and practicing physician, Student needs medical or surgical services which require Parent’s pre-authorization or consent, Parent hereby authorizes, appoints, and empowers the School to act as Parent and furnish such consent on Parent’s behalf. Parent confirms that it is Parent’s desire that the Student be furnished with such medical or surgical services as soon as reasonably possible after the need arises. Parent hereby releases and holds the School harmless from any liability which might arise from the giving of such consent. Parent agrees to reimburse the School for any medical expenditures made on Student’s behalf.

Consent: Onsite Medical Care(Required)

The Parent hereby authorizes the School to supply medical care as needed for Student (including administration of allergy medications, Epi-Pens, etc. according to the Student’s prescription from a licensed practitioner) or other minor medical care or emergency as determined to be appropriate by the School Staff.

Consent: OTC Medications(Required)

We anticipate there may be times when your student needs to take standard over the counter medication for pain relief, allergies, etc. We do not provide an onsite nurse. By checking this box, you understand this and give your child permission to self administer over the counter medications that have been approved.

Consent: Open Campus(Required)

Open Campus Acknowledgement: You understand that ICON is an open campus and that your student will be able to go with other ICON students on lunch during a designated lunch hour. This may be taken on or off campus.

Damages(Required)

Damages Acknowledgement: The parent assumes all responsibility for any damage to ICON properties caused by their student. The parent releases ICON from the liability of a student’s personal items being lost, stolen, or damaged while attending summer intensives.

Liability Release(Required)

ICON is a school that specializes in performing and visual arts. In order to support learning, we use various technical tools and processes that are tailored to meet the unique needs of each class. This may include movement, lifting, building, using tools and working with a variety of materials. This list is not exhaustive. You hold ICON harmless and free from liability.

Acknowledgement: School Rules(Required)

Students attending summer intensives will adhere to all school policies, rules, and regulations.

Acknowledgement: Transportation(Required)

I understand that it is my duty to ensure proper drop off and pick up my student to and from ICON. I understand and give ICON permission to transport my student by car, or other vehicle, in accordance with field trips or class needs. At times, I understand that my student may ride with other students or friends in order to go off campus to eat, attend an event, or the like. I release ICON from all liability if my student seeks transportation from another person not affiliated with ICON.

Acknowledgement: Health History and Treatment(Required)

The health history indicated on our summer intensive student information form is accurate so far as I know and the above-stated person has my permission to attend and participate in all activities at Iowa Conservatory. I understand all precautions will be taken for student care and supervision. I entrust care of my child to student life staff during their time on campus. Beyond this I will not hold Iowa Conservatory Faculty and Staff or Iowa Conservatory responsible or liable.

Electronic Signature: By providing my electronic signature and the date below, I acknowledge that as parent/guardian, I have completed this form and attest to the accuracy of the information provided.(Required)

Summer Intensive Student Information Form

ICON Summer Intensive Student Information Form

Student Details

Attendance and Participation

Guardian and Emergency Contacts

Health Information

Health Professional Contacts and Health History

Boarding Student Life Information

Social-Emotional/Behavioral

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