Victor J. Andrew Music 2019 Emergency Medical Form
Student Name (Full legal name, no nicknames) *
Your answer
Date Of Birth *
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Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Mother's Name *
Your answer
Mother's Cell *
Your answer
Mother's Work Phone *
Your answer
Father's Name *
Your answer
Father's Cell *
Your answer
Father's Work Phone *
Your answer
Name of Insurance Company *
Your answer
Group Number *
Your answer
Identification Number *
Your answer
Religion
Your answer
Physician's Name *
Your answer
Physician's Address *
Your answer
Physician's Phone *
Your answer
In the event we cannot contact the guardian at the above location and number, who else do you wish to be contacted for permission to treat in case of emergency?
Emergency Contact Name *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone *
Your answer
Medical History
Your answer
Please submit any and all conditions that are pertinent to your student's health for travel. Please note that if your student has allergies to foods or they are intolerant of certain foods, they should be well aware of their own needs and every accommodation will be made to fulfill their dietary needs while traveling or participating in the band events.
Food Allergies/Intolerance (please be as detailed as possible) *
Your answer
Is student a vegetarian? *
Is your student Vegan? *
Medical Problems/Considerations (if your student has occasional medical symptoms that a parent knows like an upset tummy and the remedy for it, or they had heart surgery as a baby, or seizures when they were little, but not now, let us know, or whatever else you know about your student and want to share to help us know your child) *
Your answer
Medications/Dosages *
Your answer
Epipen? *
For what reason does your child have an Epipen? Will they be carrying their own, or will our medical parent carry it for them?
Your answer
If a student is using an inhaler or nebulizer, please have student carry necessary equipment and medication with them
If it should arise, what medication can the student take, if any?
Headache? *
Your answer
Aches/Pains *
Your answer
Stomach Ache *
Your answer
Diarrhea *
Your answer
Cramping? *
Your answer
Stuffy Nose? *
Your answer
Sore Throat? *
Your answer
Allergies? *
Your answer
Constipation? *
Your answer
Check below to authorize student to take any of the above medication *
Required
Date of Authorization *
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IMPORTANT: Can the student take a GENERIC EQUIVALENT for any of the above situations? *
IN CASE OF EMERGENCY:
Check Below to Authorize *
Required
Today's Date *
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Parent/Guardian Name *
Your answer
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