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STUDENT MEDICAL INFORMATION - GVHS Music Trip 2022
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* Indicates required question
Email
*
Your email
Student First Name
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Your answer
Student Last Name
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Your answer
Today's Date
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MM
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DD
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YYYY
Student Date of Birth
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MM
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DD
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YYYY
Student Cell Phone Number
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Your answer
Parent/Guardian Full Name
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Your answer
Parent/Guardian - Cell Phone Number
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Your answer
Parent/Guardian - Work Phone Number
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Your answer
Parent/Guardian - Home Phone Number
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Your answer
Additional Parent/Guardian Full Name
Your answer
Additional Parent/Guardian Cell Phone Number
Your answer
Additional Parent/Guardian Work Phone Number
Your answer
Additional Parent/Guardian Home Phone Number
Your answer
List below any medications that the student takes. If the student requires medications during the trip, a Parent/Guardian must complete the paper form: "Parent Permission For Student Administration of Medication"
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Your answer
List any special health needs or conditions that medical personnel should be made aware of:
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Your answer
Does the student have any allergies?
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Yes
No
If yes, please list all allergies
Your answer
If yes, do any of these allergies cause an anaphylactic reaction?
Yes
No
Clear selection
If yes, does the student carry an epi-pen?
Yes
No
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Date of last tetanus shot
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MM
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DD
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YYYY
Is the student vaccinated for COVID-19?
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Yes - fully vaccinated and boosted
Yes - fully vaccinated only
No
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