Wednesday, June 29, 2011

Marching Band Health Form (Side A)

Below is the Health Form (Side A) or download the form.
Please return this form at your uniform fitting or bring it to a Wednesday ngiht (optional) rehearsal. All forms need to be in my office no later than July 20, 2011.
Thank You for taking care of this detail.
Mr. B
Alvirne High School Music Department
Gerry Bastien, District Music Coordinator
200 Derry Rd
Hudson, NH 03051
Tel 886-1265 Email: gbastien@alvirnehs.org


Please PRINT or TYPE the following information – Thank You

Student Name: ________________________________________DOB:__________

Parent/Guardian: ________________________________________

Home Address (no PO Box, Please!)_______________________________________________

Home Phone#: _______________ Cell Phone# : _______________ Work Phone # _________

IN CASE OF EMERGENCY- - PLEASE NOTIFY (Other than parents)

Name: ___________________________________________Relationship__________________

Home Address: ___________________________

Home Phone #_______________ Cell Phone#: _______________Work Phone#_____________


Health History

Family Physician:_____________________________________________Tel # ___________


Are there any illnesses or conditions for which this child is currently receiving treatment we need to be aware of?
Yes____ No_____
Please describe
Does you child have any allergies to food, medication, bees? Yes_____ No______

Reaction to what?________________________________________

Type of reaction and severity?______________________________

Does your child carry an Epi-Pen? Yes____ No______

Date of last Tetanus Immunization: ________________________________
_________________________________________________________________________________
In case of a medical emergency, I hereby authorize any licensed physician, hospital, clinic or other medical facility to hospitalize and secure treatment for my child as named above.
Heath Insurance Co: __________________________________Policy No: ____________________
Signature of Parent/Guardian___________________________________________________
DATE: _______________________
NO STUDENT WILL BE ALLOWED TO PARTICIPATE WITHOUT THIS FORM PROPERLY COMPLETED AND RETURNED.
PLEASE FILL OUT BACK OF THIS SHEET (Side B) .