Student Medical and Allergy Information
This form is in addition to the required MHSAA Sports Physical District Medical Form that all students are required to have on file.
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Email *
Student First Name *
Student Last Name *
Student Sex Assigned at Birth
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Health Insurance Carrier (Please write "N/A" if student is not covered by medical insurance.)
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Enrollee ID/Policy Number
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Group Number
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Birthdate of Card Holder (mm/dd/yyyy)
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Please list any Prescription Medications/Regularly taken OTC Medications along with Dosage, Frequency, and any special notes and instructions.
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May the following over-the-counter medications be given to your child at any band functions? (Please check all allowed medications.)
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Required
Please list any additional meds that should NOT be taken:
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Please list any Allergies including Food Allergies and Special Dietary Needs as well as special notes and instructions.
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If known, please list the date of student's most recent tetanus shot.
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List any medical or behavioral concerns you would like the camp Health Care Officer to know about and how they are handled.
Examples: Recent surgeries, acute or chronic medical conditions, or physical conditions that may limit activities.
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Release

My child has permission to engage in all prescribed camp activities, except as noted by me or an examining physician.

I understand that in the event of an illness or accident involving my student (other than those of a minor or routine nature) every reasonable effort will be made to contact a parent or legal guardian to consult with them concerning proposed treatment by professional medical personnel. However, should representatives of the Band be unsuccessful in reaching me during an emergency, I hereby give consent for a qualified physician to perform medical and/or surgical procedures deemed necessary to the welfare of the student. Further, this authorization permits said physician to hospitalize, secure appropriate consultation, order injections, anesthesia (local, general, or both) or surgery for said student if emergency conditions warrant. The undersigned does hereby assume and agree to pay any indebtedness or physician's or surgeon's fees and hospital charges for such service.

If my child uses an EpiPen and/or inhaler, I understand and will help reinforce that these devices will be in the student’s possession at all times for the entire duration of both home and away camps.
The information submitted herein is truthful to the best of my knowledge. Further, in consideration of my/my child’s participation in a Utica Community Schools (UCS) sponsored Marching Band, I/we do hereby agree, understand, appreciate, and acknowledge that participation in such marching band is purely voluntary; that such activities involve physical exertion and contact and that there is inherent risk of personal injury associated with participation in such activities, which risk I/we assume; and that I/we agree to, and hereby waive any and all claims, suits, losses, actions, or causes of action against UCS, its members, officers, representatives, committee members, employees, agents, attorneys, insurers, volunteers, and affiliates based on any injury to me, my child, or any person, whether because of inherent risk, accident, negligence, or otherwise, during or arising in any way from my/my child’s participation. I/we understand that I am/we are expected to adhere firmly to all established policies of UCS and Utica High School. I/we hereby give my consent for the above student to engage in marching band and for the disclosure to UCS of information otherwise protected by FERPA and HIPAA for the purpose of determining eligibility for marching band. My child has my permission to accompany the marching band as a member on its out-of-town trips.I understand that Utica Community Schools, the Utica High School Band and Orchestra Boosters and their representatives shall not be, nor later become, liable or responsible in any way in conjunction with services, for any death, injury, damage, delay or irregularity which may occur while participating in this activity.I fully understand that I am giving permission for a Utica High School Instrumental Music Program representative to give my child the medications as listed on this form and any attached sheets should the need arise. I have listed all known allergies and medications that my child cannot take.

Student Signature

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Note: If completing this form on a computer, your typed name is the legal equivalent of a hand-written signature
Parent/Guardian Signature
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Note: If completing this form on a computer, your typed name is the legal equivalent of a hand-written signature
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