2019-2020 BWHS Band Medical Form
Please fill out the information below. All information entered below is confidential and will only be viewed by the band directors. This information will only be used in the event of an emergency. We will not use the information entered below to solicit volunteers.
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Student Name *
Student Date of Birth *
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Home Address *
City *
Zip Code *
Primary Insurance Company *
Group Number *
Policy Number *
Name of Policy Holder *
Dental Insurance Company
Dental Group Number
Dental Policy Number
Dental Name of Policy Holder
List allergies to food, medications or other concerns. If none, so state. *
List any Health Concerns. If none, so state. *
Grant Permission for the Band Directors to administer school approved over the counter medicines? *
Student's Physician *
Physician Office Number *
Parent/Guardian Name *
Parent/Guardian Cell Number *
Parent/Guardian Work Number *
Parent/Guardian Name
Parent/Guardian Cell Number
Alternate or Emergency Adult Name and Relation to Student. (Name/Relation) *
Alternate or Emergency Adult Cell Number *
Please type your full name. By typing your name you are giving the appropriate school personnel authority to call EMS to transport and to obtain emergency medical care. *
Today's Date *
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