Sounds of Dyn-O-Mite Medical History Form
PLEASE ANSWER ALL QUESTIONS
FULL NAME *
FIRST MIDDLE LAST
A NUMBER *
ALCORN STUDENT ID NUMBER BEGINNING WITH A
DATE OF BIRTH *
xx/xx/xxxx
INSTRUMENT *
BAND CLASSIFICATION *
READ CAREFULLY...IF THIS IS YOUR VERY FIRST YEAR IN THE SOUNDS OF DYN-O-MITE, SELECT FRESHMAN, DESPITE YOUR YEAR IN SCHOOL. IF THIS IS YOUR SECOND YEAR, SELECT SOPHOMORE...THIRD YEAR, JUNIOR...FOURTH YEAR, SENIOR.
DORMITORY *
ROOM NUMBER *
USE N/A IF YOU RESIDE OFF CAMPUS
EMAIL ADDRESS *
HOME ADDRESS *
HOME CITY *
HOME STATE *
NO ABBREVIATIONS
HOME ZIP CODE *
PHONE NUMBER *
(XXX)XXX-XXXX
EMERGENCY CONTACT FULL NAME *
PARENT OR GUARDIAN FULL NAME
EMERGENCY CONTACT PHONE NUMBER *
(XXX)XXX-XXXX
The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be released without your written permission.
GENDER *
Required
FAMILY AND PERSONAL HEALTH HISTORY *
CHECK ALL THAT APPLY
Required
ARE YOU CURRENTLY TAKING ANY MEDICATIONS *
PLEASE LIST ANY DRUGS, ASTHMA INHALERS, MEDICINES, BIRTH CONTROL PILLS, VITAMINS AND MINERALS (PRESCRIPTION AND NONPRESCRIPTION) YOU USE AND INDICATE HOW OFTEN YOU USE THEM. *
USE N/A IF IT DOESN'T APPLY
DO YOU HAVE AY MEDICATION ALLERGIES *
WHAT ARE YOU ALLERGIC TO? *
USE N/A IF IT DOESN'T APPLY
HAVE YOU OR DO YOU NOW HAVE... *
CHECK ALL THAT APPLY
Required
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