Georgia Bridgemen Health Form
The form must be on file with the Lowndes High Georgia Bridgemen for your student to participate in any band activities.  By filling out this form you are answering these questions to the best of you knowledge.  Please use N/A for anything not applicable.
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Student Name *
Date of Birth (MM/DD/YEAR) *
Section *
Graduation Year *
Home Address (Street, City, Zip Code) *
Parent/Guardian #1 Name *
Parent/Guardian #1 Cell Phone Number *
Parent/Guardian #1 Work Phone Number
Parent/Guardian #1 Email (This is how you will receive your band statements) *
Parent/Guardian #2 Name
Parent/Guardian #2 Cell Phone Number
Parent/Guardian #2 Work Phone Number
Parent/Guardian #2 Email
In Case of Emergency and Parent/Guardian Cannot be Reached, Please Contact the Following: (Please provide full name and contact number(s) *
Does student have any allergies? *
Has your student ever been diagnosed with following? Check all that apply
Please list all medications that your student is taking.  Please include OTC medicine as well..  Please mark N/A if no medicines are being taken. *
Does your student have any condition that will interfere with physical activity? *
Your student's Doctor's name *
Insurance, Policy Holder, Group Number, Policy Number *
Disclaimer:
In case of an emergency I understand that every effort will be made to contact the student's Parent or Legal Guardian.  In the event the Parent/Legal Guardian cannot be contacted I hereby give my permission to the physician selected by the Band Director or the Band Nurse to secure proper treatment which may include hospitalization, anesthesia, surgery or injections of medications to my student.  I understand this may include transportation to a medical facility.  I understand that I will be responsible for any charges incurred in the treatment of my student under such circumstance.

I give permission for the band nurse to administer OTC medications (Tylenol, Pepto-Bismol, Cold Medications) and first aid for cuts, scratches, bruises, etc.  I also accept full responsibility for any medications my student may take without the knowledge of the band nurse and relieve the school, Band Directors and Band Nurse of any legal responsibility.

By submitting this form, I agree to the Disclaimer above.


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