OVPC Health Form
OV Patriot Choir Health Form

Matthew Latta, D.M.
Choir Director
Music Department Chair
Owen Valley Middle/High School
622 State Rd 46, Spencer, IN 47460
Office Phone: 812-829-2266 (Ext. 328)
Personal Cell Call/Text: 812-236-0740
Fax: (812) 829-2266  
E-mail: mlatta@socs.k12.in.us

Dear Parents/Students:

In an effort to better ensure the health and safety of our students, we are requiring this Medical Health Form to be completed and signed for the choirs. This will cover your student for the 2020/2021 school year.

The information contained in this form is confidential.

Permission for obtaining medical care will only be used for emergencies or serious illness. Parents will be contacted as soon as possible.

Thank you for your cooperation in this matter.
Sign in to Google to save your progress. Learn more
Email *
Student Name *
Emergency Contact Name #1 *
Emergency Contact #1 Cell Phone Number for Call/Text *
Emergency Contact Name #2
Emergency Contact #2 Cell Phone Number for Call/Text
Preferred Physician's Name (if applicable)
Preferred Physician's Phone Number (if applicable)
My student's existing conditions/allergies include:
Check that apply
Does your student take/have medication for this condition?
Food Allergies (peanuts/tree nuts)
Bee Stings
Asthma
Heart Conditions
Migraines
Seizure Disorders
OTHER
NONE
If your student is allergic to anything other than peanuts or tree nuts, please elaborate here:
If you chose OTHER (above), please elaborate:
I give permission to the school nurse/designee to share information relevant to my child’s condition with appropriate personnel when needed to meet my child’s health and safety needs. I also acknowledge that the OV Patriot Choir will act in good faith on behalf of my student and I give them permission obtain emergency medical care for my student.  I understand that I will be contacted as soon as possible if an emergency occurs. *
Required
Electronic Signature *
Today's Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Spencer Owen School Corp. Report Abuse