Athens Orchestras Health Form 2023-2024 School Year

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Necessary for Fall Camp/Spring Trip. To be filled out once per year

Student FIRST Name *

**REQUIRED

Student LAST Name *

STUDENT Cell Phone Number *

This will be viewed by Mr. Quinn for trips (including camp) and will be given to the student's chaperone IF they go on the spring trip/camp.

Student's Grade Level as of Fall 2023 *

Sex *

**REQUIRED

Male

Female

Prefer not to say

Preferred Pronouns? (optional)

Parent/Guardian Name AND Cell Phone Number *

**REQUIRED

Secondary Contact Name and Number (if desired)

ALLERGY INFORMATION *

My child does not have ANY ALLERGIES

My child has a FOOD allergy (please explain below)

My child has a MEDICINE allergy (please explain below)

Other:

Required

Please elaborate on your child's allergies (types of food, medicine, etc.)

Any other information that will help us take care of your student?

We have the following medications available for your student's use, if necessary. Please check next to each medication we may administer to your child. IF NONE ARE CHECKED, NONE CAN BE GIVEN FOR ANY REASON (headache, fever, allergy, insect bites, etc.) *

**REQUIRED

Tylenol (Acetaminophen)

Motrin (Ibuprofen)

Benadryl (Diphenhydramine)

Sudafed (Pseudoephedrine)

Cough Syrup (Alcohol-free, Robitussin)

Benadryl Topical

Antibiotic Ointment (Neosporin, bacitracin)

BandAid (....I wish we were joking, but we need your permission for this.)

NONE, PLEASE DO NOT ADMINISTER ANY OF THESE TO MY CHILD FOR ANY REASON

Required

PARENT AUTHORIZATION AND CONSENT: by typing your name, you acknowledge the above to be true to the best of your knowledge, and the person noted may participate in all activities except as noted. *

**REQUIRED

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