HCHS Band Medical Form 2017-2018
Full Name of Student
Your answer
Date of Birth
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Age
Your answer
Home Phone
Your answer
Parent or Guardian #1
Your answer
#1 Work Phone
Your answer
Parent or Guardian #2
Your answer
#2 Work Phone
Your answer
Name of another party if the above person(s) can't be reached
Your answer
Relation
Your answer
Phone
Your answer
Students Physician
Your answer
Physicians Phone Number
Your answer
Student is allergic to the following medications
Your answer
Student has the following allergies
Your answer
Student has the following allergies
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Student is authorized to take the following medications
Your answer
Date of last Tetanus Shot
Your answer
Check if any of the following apply
Other pertinent information concerning the students medical condition
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Is this student covered by Health Insurance?
Health Insurance Company
Your answer
Policy Holder
Your answer
Policy Number
Your answer
I hereby authorize the band director or representative of the Hart County High School Band to seek Medical attention for the student listed above. I also grant my permission for this student to participate in all scheduled school approved trips.
By agreeing, the parent or guardian digitally signs this agreement.
Name of Agreeing Parent or Guardian
Your answer
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