2019 / 2020 CRHS Band Health Report / Student Profile
This form must be completed and returned by May 16, 2019.  Please notify staff and resubmit form if any changes occur.
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Student Name *
Date of Birth *
Age *
Sex *
Name of Health Insurance Company *
Insurer Telephone Number *
Policy Number *
Family Doctor *
Clinic Phone *
Hospital Choice (if possible)
For an emergency, please provide parent/guardian name, relationship and phone number: *
Relationship to Student *
Phone Number *
For an emergency, please provide parent/guardian name, relationship and phone number:
Relationship to Student
Phone Number
In an emergency, if unable to reach parent or guardian, please contact: *
Relationship to Student *
Phone Number *
Health History
If your answer is "yes", fill out the section below. If your answer is "no", type NA for not applicable in the section below.
Is the student taking any medication? *
If yes, describe *
Allergic Reactions? *
If yes, describe *
Diabetic? *
If yes, type and dosage of medication *
Asthma/Inhaler? *
If yes, type and dosage of medication *
Recent exposure to contagious disease? *
If yes, explain *
Sleepwalking? *
If yes, explain *
Fainting? *
If yes, explain *
Permission given for staff to administer over-the-counter medication? *
Type (check all that apply) *
Other (please indicate)
Date of last Tetanus Booster: *
Any other information or directions from parents:
Health History Agreement
This health history is correct, so far as I know, and the person herein described has permission to engage in all trip activities except as noted by me.  In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as named on this form.  I further agree to release all Anoka-Hennepin Music Department members and sponsoring organizations from all claims or demands for myself and on behalf of my children, against said sponsoring A-H Music Department members and organizations, their members, agents, representatives, or employees for any personal injury and/or property damage that may be suffered.

Parent Name and Date *
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