Charger Pride Forms 2021-2022
Please be prepared to spend a few minutes to complete these forms. You will need access to your student's medical information, including doctor information, insurance information, etc. We appreciate your prompt attention to this form.
* Required
Student First Name
*
Your answer
Student Last Name
*
Your answer
Emergency Contact #1
*
Please enter first and last name. Please designate person other than parent/guardian. Parents/guardians will always be notified first in event of an emergency.
Your answer
Relationship to Student
*
Grandparent, Aunt, Neighbor, etc
Your answer
Best Phone Number to Use
*
(xxx) xxx-xxxx
Your answer
Alternate Phone Number to Use
(xxx) xxx-xxxx
Your answer
Emergency Contact #2
*
Please enter first and last name. Please designate person other than parent/guardian. Parents/guardians will always be notified first in event of an emergency.
Your answer
Relationship to Student
*
Grandparent, Aunt, Neighbor, etc
Your answer
Best Phone Number to Use
*
(xxx) xxx-xxxx
Your answer
Alternate Phone Number to Use
(xxx) xxx-xxxx
Your answer
Medical Insurance Provider
*
Your answer
Insurance Plan Title
*
Type "unknown" if a title does not exist
Your answer
Insurance Group Number
*
Enter "unknown" if group number does not exist
Your answer
Insurance Member ID Number
Your answer
Name of Family Physician
*
Please include first and last name.
Your answer
Physician's Office Phone Number
*
(xxx) xxx-xxxx
Your answer
Please list any known allergies:
Your answer
Please list any medications the student is currently taking:
Your answer
Special Medical Needs and/or Medication Needs
Please list any special medical concerns (ex. diabetes, seizures, etc.) and/or medications needs . Please also share any information that will allow us to more adequately care for your student.
Your answer
Medical Options
*
I understand rehearsals and activities of the band will be adequately staffed and that precautions will be taken to avoid sickness or injury. However, I do hereby give my permission to the student named above to receive medical attention.
I do not give consent to provide emergency medical attention to my student. In such an event, I wish the school staff to take no action.
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