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Etowah Band Medical Information
Please fill out the following form as completely as possible. This is to help us in the unlikely event your student requires assistance during a practice or performance.
If you have any questions you may email Mr. Long (
stephen.long@cherokeek12.net
) or the Booster Presidents (
etowahbandpresident@gmail.com
).
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Primary Street Address
*
Your answer
Primary City
*
Your answer
Primary Zip Code
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Your answer
Student Birthdate
*
MM
/
DD
/
YYYY
Student year of graduation
*
Choose
2021
2022
2023
2024
Primary Parent/Guardian Name
*
Your answer
Primary Parent/Guardian Emergency Phone Number
*
Your answer
Primary Parent/Guardian Email
*
Your answer
Secondary Emergency Contact Name
*
Your answer
Secondary Emergency Contact Phone Number
*
Your answer
Secondary Emergency Contact Email
*
Your answer
Additional Emergency Contact Name
Your answer
Additional Emergency Contact Phone Number
Your answer
Additional Emergency Contact Email
Your answer
Please list all know allergies - including medications, foods, animals, insect bites, stings, and the environment. (If none type NONE)
*
Your answer
Please list all know conditions - including asthma, diabetes, low blood sugar, blood pressure, heart conditions, or other conditions that may help in caring for your student in an active environment. (If none type NONE)
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Your answer
Please list all medications currently being used by the student. If this list changes, please contact Mr. Long via email. (If none type NONE)
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Your answer
I understand that if a parent or guardian cannot be reached, or that immediate attention is required, the EHS Band or any of its designated volunteers has my permission to seek appropriate medical attention for my child.
*
Yes
No
By typing my First and Last name, I am confirming that all information submitted on this form is accurate and truthful to the best of my knowledge. I understand that if any of this information requires updating it is the responsibility of the Parent/Guardian to contact Mr. Long to notify him of those changes.
*
Your answer
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