HEALTH REQUEST FORM/INFO

 

STUDENT NAME__________________________________  BIRTHDATE ___________________

 

I, the undersigned, being the parent, legal next-of-kin, or legal guardian of __________________________

hereby authorize any necessary medical treatment for this person while participating in any Heritage High School Band function.  I also guarantee payment of all charges incurred during medical treatment.

 

In regard to such person, I submit the following information:

 

1.        Allergies to foods, medications, etc.  If none, state as such.  __________________________________

__________________________________________________________________________________

 

2.        Special medical problems or health conditions.  If none, state as such.  _________________________

__________________________________________________________________________________

 

3.        Medication(s) or prescription(s) to be used by the student and purpose for each.  If none, state as such.

__________________________________________________________________________________

 

4.        I give my permission for the above named to take the following medications while participating in   band activities.  (Please circle)

 

Acetaminophen (Tylenol)        Ibuprofen (Advil)                Benedryl        Dramamine    Mylanta

Imodium (anti-diarrhea)        Advil Cold & Sinus        Sudafed         Aspirin

 

5.        Date of last tetanus shot  __________________________________

 

6.     Family Physician ____________________________           Phone ____________________

 

7.     Person (other than parent or guardian listed below) and phone number of emergency contact(s):

NAME_____________________________                    NAME _____________________________

PHONE ____________________________             PHONE ____________________________

Additional Emergency Phone #’s _______________________________________________________

 

8.        Parents/Guardian:

       Name _____________________________________________________________

       Home Address ______________________________________________________

       City __________________    State ____________                Zip _________________

       Phone:  Home ___________________

       Work:   Father  ___________________                  Mother ___________________

 

9.        Health insurance carrier _______________________________________________________

        Policy #____________________________________________________________________

 

I authorize the Heritage High School Band Staff to act in my behalf in seeking medical assistance for the above named student in the event of an emergency.

 

Parent’s/Guardian’s signature: _______________________________________________________

 

Parent’s Email:___________________________________________________________________