Big Mac Band -                                                                                           Student Medical Form
In preparation for the upcoming band season, please complete the following form as soon as possible.  We will have volunteer medical personnel with the band during practices and performances.  They will provide the group with medical coverage and have access to any information that you submit.  Be assured that all information provided will be kept confidential and electronic records will be deleted at the end of the school year.

The Canon-McMillan School District and Canon-McMillan High School does NOT permit students to carry non-prescription medications (Tylenol, Advil, cough/cold meds, etc) with them.  The medical personnel will have over-the-counter medications available for students on an as needed basis and require the permission of a parent/guardian before administering medication(s) to a student.  Please indicate your consent and choice of medications they may administer to your child on this form.  The medical personnel will follow the dosage and administration instructions provided on the medication labels.  

Students who require prescription medication (inhalers, Epi-Pens, insulin, etc) must remember to bring their medication with them to every practice and performance.  All prescription medication MUST be in a container as dispensed by the pharmacist with the student's name clearly printed on it.

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Email *
Student's Last Name *
Student's First Name *
Date of Birth *
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DD
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YYYY
Allergies *
What information would you like the medical professionals traveling with the band to know:
I give my permission to administer any of the following over-the-counter medications to my child as needed:
Does your child have/carry the following:
Current prescription medications (name of medication, dosage, frequency)
My child has been instructed about the proper use of the prescription medications listed above and has my permission to safely self-administer them.
Clear selection
My child requires direct assistance to administer medications listed above
Clear selection
Health History
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If other or if you checked any condition listed above, please explain:
Emergency Contact #1 (Name) *
Emergency Contact #1 (Phone number) *
Emergency Contact #2 (Name) *
Emergency Contact #2 (Phone number) *
A copy of your responses will be emailed to the address you provided.
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