Request edit access
2019 Uintah Marching Band Medical Release form
IMPORTANT! PLEASE READ: This form must be submitted before May 16th. 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 put NA in the blank to insure accurate information. Incomplete forms can not be accepted.

Mr. Gibson is a Certified Advanced Emergency Medical Technician for the State of Utah. He will personally see to all medical needs prior to seeking advanced medical help. If emergency care or a doctor are needed the student will be transported to definitive care as quickly as possible and the parents will be notified.

Since medical information is considered privileged information rest assured that this information will be kept private and used only as HIPPA allows. For the safety of your child the more complete this information is the better we can see to his/her care. Not all questions are marked as required to submit the form, but the more you can fill out the better. Be as complete as you can, but if you just don't know leave it blank if it is not required.

Student's full legal name *
Your answer
Student's Date of Birth
MM
/
DD
/
YYYY
Gender *
Primary Emergency Contact *
Who do you want us to call first?
Your answer
Primary Contact Phone Number *
Where can we reach you at any time?
Your answer
Secondary Emergency Contact
Your answer
Secondary Contact Phone Number
Your answer
List any operations that the student has had in the last year:
Your answer
Year Graduating *
Any medical History items we should know about?
Your answer
Student's Blood Type if Known:
Your answer
Student's last Tetanus Shot if known:
MM
/
DD
/
YYYY
Does the student have a history of any of the following? *
Mark all that apply
Required
If you marked any of the above please comment below.
If I need to know more fill this out. If your student uses a Glucagon injection kit or an Epi Pen, please provide one to be kept in the medical kit throughout the season.
Your answer
List any allergies to medications:
Your answer
Please list all medications that the student is taking
Your answer
Please indicate any medical procedures you would not like performed
For example blood transfusion, etc.
Your answer
Student's Physician
Your answer
Physician's Phone number
Your answer
Name of the Insurance Policy holder:
If the student is covered under insurance, who holds the policy?
Your answer
Insurance Company Name
Your answer
Group Number
Your answer
Policy Number
Your answer
List the over the counter drugs you are comfortable with a staff member distributing to your student:
If you don't want us to do this leave them blank. We will dispense the dose indicated on the packaging if indicated by you, and needed.
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 above is required for emergency treatment of your student). 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 ________________________________ (student’s name) receives whatever medical treatment is necessary in the event of an emergency. *
Parent / Guardian Name
Your answer
Parent Electronic Signature
By typing your name here you are signing this document and indicating that it is full and complete to the best of your knowledge.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service