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:___________________________________________________________________