Emergency Medical Information
Personal Medical Information Form/Emergency Information CHHS Band
First Name
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Male/Female?
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Social Security Number
Your answer
Phone Number
Your answer
Health History: Check if you have any known or pre-existing conditions
Date of Last Tetanus Shot
Your answer
Current Prescription Medications
Your answer
Known Allergies
Your answer
Health Insurance Provider
Your answer
Health Insurance Group and/or Member ID (please specify)
Your answer
Health Insurance Phone Number
Your answer
Physician Name
Your answer
Physician Phone Number
Your answer
Emergency Contact #1 Name
Your answer
Emergency Contact #1 Phone Number
Your answer
Emergency Contact #1 relation to you
Your answer
Emergency Contact #2 Name
Your answer
Emergency Contact #2 Phone Number
Your answer
Emergency Contact #2 relation to you
Your answer
As the parent/guardian of the student listed for this online Emergency Information Form: I, hereby consent to emergency medical care at a hospital, and diagnosis procedures and medical treatment by the attending physician in the emergency department.I hereby agree to hold the staff of Central Hardin High School, the Hardin County Board of Education, & CHHS Band Boosters harmless from any liability resulting from any medical treatment.I hereby authorize any director of the Central Hardin High School Band to sign any and all necessary releases, documents, or authorizations for my child listed on this form to receive any and all necessary emergency medical treatment.I hereby agree to allow any director of Central Hardin High School Band or medical aid appointee to administer first aide or emergency aide and to seek emergency care for the individual listed on this form.
Digital Signature: By entering you initials below, you consent to this Digital Signature and signify your agreement with the statement above
Your answer
DO NOT SUBMIT TWICE - CLICK SUBMIT ONLY ONCE - if you need to make changes after submitting, contact a band director
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