Monday, July 2, 2012

ALL ABOUT BAND (Part 5) 7-2-12 (Health Form Part 1)

Below is the health form for band camp-

 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 .