Part 1 of 3 - McAnally Band Medical History
Student Medical History
Email address
Students First Name and Middle Initial
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Students Last Name
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Students Birth Date
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Parent(s)/Guardian(s) Name
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Email Address of Parent/Guardian Submitting This
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Work or Cell Phone
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Alternate Emergency Contact Name
Your answer
Alternate Contact Work/Cell
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Physician Name
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Physician Office Number
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Insurance Company
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Policy #
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Insurance Phone
Your answer
Medical History (Has your child ever experienced a medical problem associated with any of the following? Check all that apply)
Please provide specific information regarding each of the above items checked
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Please list any medications which your child takes on a regular basis. Include the medication name, dosage, and frequency
Your answer
ALLERGIES - Is your child allergic to medications? (Please list) Any other allergies? (Please list)
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Please indicate which of the below over the counter medications that you approve to be dispensed to your student at the discretion of the Band Directors or a designated chaperone.
Please check to indicate your agreement to sign and submit electronically
Required
Parent/Guardian Signature (by typing your name you agree to submit your signature electronically)
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Date
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YYYY
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