Charlton County Band Student Medical and Health Release Form 2022-2023
Important! Please read! This Medical/Health form will be kept with the medical kit at all times in case of a medical emergency involving your student. Make sure all blanks are completed. If an item does not apply to your student, please select NA as needed to insure accurate information. Incomplete forms cannot be accepted. Please make sure that the Primary and Secondary contact is someone who can be reached at anytime while your student is participating in a band activity. If you have more than one student in the band, you must fill out a separate form for each child.
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Email *
Student's Full Name *
Student's Birth Date *
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DD
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Sex: *
Grade (Beginning August 2022) *
Instrument (Marching Band) *
Instrument (Concert Season) *
Primary Emergency Contact: The Primary contact must be able to be reached at anytime when the student is participating in a band activity if the student's parent/guardian is not in attendance. *
Primary Emergency Contact: Home Phone *
Primary Emergency Contact: Work Phone *
Primary Emergency Contact: Cell or Other Phone *
Primary Emergency Contact: Email Address *
Secondary Emergency Contact: The Secondary contact must be able to be reached at anytime when the student is participating in a band activity if the student's parent/guardian is not in attendance. *
Secondary Emergency Contact: Home Phone *
Secondary Emergency Contact: Work Phone *
Secondary Emergency Contact: Cell or Other Phone *
Secondary Emergency Contact: Email Address *
Secondary Emergency Contact: Email Address *
Responsible Party (in case a hospitalization is required) *
Responsible Party: Home Phone *
Responsible Party: Work Phone *
Responsible Party: Cell or Other Phone *
Responsible Party: Email Address *
Responsible Party: Address and Zip Code *
Please read! This section will describe your student' health history. Please answer all questions. If the question does not apply to your student, put NA in the blank. Incomplete forms will not be accepted.
Please list any operations your student has had in the last year. *
Does your student have any specific health concerns such as hyperventilating, fainting, seizures, etc...? *
Tetanus (Date of last injection) *
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DD
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YYYY
Student's Blood Type *
Does the student have or ever had any of the following? *
Required
Does the student have any allergies? Please list ALL! Note: If your student uses an Epi-pen, please provide one to be kept in the medical kit throughout the season. *
List ALL medications your student will be taking during the marching and concert seasons. *
Is your student presently under the care of a physician for any reason? Please explain if yes. *
Medical Exemptions (Blood transfusions, etc.) *
Student's Physician (First and Last Name) *
Student's Physician Phone *
Student's Physician Hospital *
Limited Power of Attorney: In the event that a serious emergency arises, it may be necessary for a physician to attend to your student before the staff can reach you or your designated physician. Such emergency care can be provided only if you sign the following Authorization to Provide Medical Treatment. All information below is required for emergency treatment of your student. Completing the questions in the Authorization to Provide Medical Treatment question serves as your electronic signature and permission for your student to receive medical treatment.
Authorization to Provide Medical Treatment: I hereby give the band director or chaperone in charge of my son/daughter limited power of attorney to act in my absence and see that my child receives whatever medical treatment is necessary in the event of an emergency. (Please sign your name). Completing the questions in the Authorization to Provide Medical Treatment question serves as your electronic signature and permission for your student to receive medical treatment. *
Authorization to Provide Medical Treatment: I hereby give the band director or chaperone in charge of my son/daughter limited power of attorney to act in my absence and see that my child receives whatever medical treatment is necessary in the event of an emergency. (Please sign your student's name). Completing the questions in the Authorization to Provide Medical Treatment question serves as your electronic signature and permission for your student to receive medical treatment. *
Family Insurance Company Name *
Family Insurance Company Phone *
Family Insurance Company Policy Number *
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