Band Health Form
Student's First name *
Your answer
Student's LAST name *
Your answer
Parent (s) Names *
(Please write in ALL parents Names i.e. John and Jane Doe, Josh and Helen Smith
Your answer
Parent's Emergency Phone #'s *
ALL phones that we can call: All Cell #'s, and Home #'s etc.
Your answer
Parents' Email(s) *
separate emails with a comma, please :)
Your answer
Other Emergency Contact: Name AND relation *
i.e. John or Jane Doe -Grandparents
Your answer
Other Emergency Contact PHONE # *
Please provide home and cell if applicable.
Your answer
Health Care Provider *
Priority, Blue Cross Blue Shield, MIChild, etc.
Your answer
Health Authorizations Signatures: my son/daughter/student can receive NON-prescription medicine on band trips *
i.e. (acetaminophen, cough syrup, etc.)
Required
Health Authorizations Signatures: trip leaders may authorize EMERGENCY medical treatment for your son/daughter/student.
Important Health issues -Allergies, special conditions, etc. *
If none please enter N/A or None
Your answer
Bus Permissions: By Checking this box, I give permission for my child to ride the bus to and from competitions and festivals *
Required
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