HCHS Band Medical Form 20-21
Full Name of Student
Date of Birth
Age
Home Phone
Parent or Guardian #1
#1 Work Phone
Parent or Guardian #2
#2 Work Phone
Name of another party if the above person(s) can't be reached
Relation
Phone
Students Physician
Physicians Phone Number
Student is allergic to the following medications
Student has the following allergies
Student has the following allergies
Student is authorized to take the following medications
Date of last Tetanus Shot
Check if any of the following apply
Other pertinent information concerning the students medical condition
Is this student covered by Health Insurance?
Clear selection
Health Insurance Company
Policy Holder
Policy Number
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.
Clear selection
Name of Agreeing Parent or Guardian
Submit
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