Student Health Form
Student's Name *
Date of Birth *
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Home Phone Number *
Student's Home Address *
Parent/Guardian Name *
Parent/Guardian Phone Number *
Parent/Guardian's Work Phone Number *
Emergency Contact: Name and Phone Number *
List of Medications student is currently taking along with dosage and frequency. *
Select all of the boxes that best describe the students health history *
Required
Please explain if you checked any of the boxes above *
Is the student under medical treatment at present? If yes, what is the reason? *
Physician's Name and Phone Number *
The undersigned does hereby authorize the staff and sponsors of the Washington High School Choir with whom my travels or participates as agent for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general and special supervision of any licensed physician or dentist at the hospital or elsewhere. The undersigned also authorizes the staff/or sponsors to administer first aid treatment as deemed necessary in the absence of a physician. The undersigned assumes complete financial responsibility for any and all care rendered or otherwise provided under this authorization. The authorization will remain effective while the above minor is en route to and from or involved with or participation in all Washington High School Choir activities, unless revoked in writing by the undersigned and delivered to the aforesaid agent. This authorization shall not be affected by the death or disability of the undersigned. Please type your name below to serve as your signature of this document and your relation to the minor above. *
Health Insurance Company and Policy Number *
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