2021 Trojan Marching Band Medical Form

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Please fill out ONLY if you plan to fully commit to the entire Marching Band season. Please complete this form with a parent/guardian by your side.

First Name *

John

Last Name *

Smith

Address *

Street, City, Zip

Date of birth *

Cell phone *

Or Home Phone - Best contact Number for you

Family physician *

Family physician office number *

Health Insurance Co. *

Policy Number/Member ID # (individual) *

If unknown put N/A

Group No. *

If unknown put N/A

Please list any health information that might be needed. Also, please specify if you have given your child permission to carry and consume any medications during rehearsals/trips: (Allergies, inhalers, chronic conditions,recent injuries, illness, etc.) *

Please list any medication your child will be taking throughout the season: *

If none put "None"

In the event of injury or illness to my child during his/her participation in this activity, if the parents/guardians mentioned below cannot be reached, we hereby give permission for the necessary medical treatment to be given to our child. *

This is an Online Parent Signature - Please have your parent or guardian type their name

Parent/guardian cell phone *

BEST NUMBER TO REACH YOU

In the event that you cannot be reached, please list two emergency contacts we may call for advice or direction in caring for your child in case of a serious accident, illness, operation, or other disaster. *

Please list name, number, and relationship to child

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