Student Medical Information Form - Pendleton Heights HS Band
The information on this form will be kept confidential and only shared with PHHS faculty, chaperones (if necessary) and medical staff (if required).

Pendleton Heights School policy states that any medications have to be distributed by an adult. All medications prescription or OTC needs to be brought to the school in a zip lock bag marked with the student's name. Any prescription medication should be avoided during band events. Prescription medications should be taken at home before band events if possible. Any OTC medications that may be needed needs to be brought in its original package. (Car Sickness Medications, diarrhea, allergy medication etc.) Student's that need to carry their inhaler or Epi-Pens may do so if the school has on file the proper paperwork. Students may carry cough drops.


Student Last Name *
Your answer
Student First Name *
Your answer
Age *
Your answer
Parent to contact in case of an emergency *
Your answer
Parent telephone # to contact in an emergency *
Your answer
2nd Person to contact in case of an emergency *
Your answer
2nd Person's telephone # to contact in an emergency *
Your answer
Health Insurance Provider
Your answer
Student's Home Address *
Your answer
List any known food, animal or environmental allergies
Your answer
List any prescription medications that your child is currently taking (Name; Dose; Frequency; Reason)
Your answer
Check any conditions for which the child is being treated:
PHHS Staff and parent chaperones have permission to give administer the following medications to my child:
(please add the prescription medications that your child takes in the "other" category)
Is there ANY extra information that the PHHS staff should be aware of?
Your answer
If your child should require medical attention the Pendleton Heights High School faculty has my permission to treat on-site or take my child to a doctor, hospital, or any other medical facility for necessary medical treatment, and I authorize the release of medical information included in this document to the health care professional administering the medical treatment to the participant. *
By typing my name below, I verify that the information above is true.
Your answer
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