2021 Greater Johnstown Indoor Percussion Medical Form
First name *
Last name *
Date of birth *
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DD
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Address *
Home Phone *
Cell Phone *
Family Physician *
Family Physician office number *
Health Insurance provider *
Policy Number *
Group Number *
Please list any health concerns including allergies, recent injuries, surgeries and recent major illness. *
Please specify any medication the student is currently taking. *
Please specify any medication your child has permission to carry and consume during rehearsals/trips. (allergies, inhalers, ibuprofin, etc.) *
If your child currently under a physician's care? If yes, please explain. *
Is your child currently under counseling. *
Parent/Guardian full name(s) *
Parent/Guardian phone number(s) *
Parent/Guardian e-mail(s) *
In the event you cannot be reached, please list 2 emergency contacts we may call for advice in the event of injury or illness. (name, relation to student, phone number) *
In the event of injury or illness and I and the parents/guardians above cannot be reached, I/we hereby give permission for first aid to be administered by instructors or responders as needed and any possible necessary medical treatment to be given to our child at the discretion of qualified medical personnel. *
(Parent/Guardian signature) By digitally signing below I confirm that I have provided all information truthfully and fully and understand that this form is completely confidential and for the safety of the students. *
(Student signature) By digitally signing below I confirm that I have provided all information truthfully and fully and understand that this form is completely confidential and for the safety of the students. *
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