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Emergency Form
All Students participating in Marching Band or Color Guard must have an Emergency Form on file. Students will not be allowed to participate without the required forms. All information is CONFIDENTIAL.
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* Indicates required question
Email
*
Your email
Student Name (Last, First)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Student Address
*
Your answer
Student Cell #
*
Your answer
Parent/Guardian Name
*
Your answer
Parent Phone Numbers, H=Home, W = Work, C=Cell
*
Your answer
Parent Address (if different from student)
Your answer
In the space below, please name 3 Emergency Contacts with home and cell numbers (if both)
*
Your answer
Please list any known allergies, reaction and treatments
*
Your answer
Known Medical Conditions (in the last 12 months)
*
Your answer
Please list current medications (add a * if students carry with them regularly)
*
Your answer
Physician name and phone
Your answer
Please list the following: Insurance Carrier, Address, ID Number, Phone, Policy Holder Name and Date of Birth for Policy Holder (only to be used in case of emergency)
*
Your answer
I give permission that my child may be given:
Tylenol
Ibuprofen
This constitutes a written signature: In the event of an emergency, I give permission for medical treatment via emergency room and/or physician.
*
I agree
Please type your name below with the date. This constitutes an electronic signature that you have filled out this form to the best of your knowledge.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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