Student Medical Form
Medical Form for the 2023-2024 Marching Season

Families with Multiple Band Members MUST complete one form for each student

Manheim Central Marching Barons
Student Health History
Manheim Central School District
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Email *
Student First Name *
Student Last Name *
Date of Birth *
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Age *
Home Address (Please include house number, street, city, state, and zip code) *
Resides With *
Parent/Guardian Email Address *
Emergency Contact 1 Name (Must be Parent/Guardian) *
Emergency Contact 1 Phone Number *
Emergency Contact 2 Name *
Emergency Contact 2 Phone Number *
Primary Health Care Provider Name and Phone Number *
Parent/Guardian Signature
Please note that typing your name in the boxes below will count as an electronic signature for the purposes of this form.
Parent/Guardian Signature:  I consent for my child, to take part in the Marching Band practices and performances I consent for basic first aid to be administered as needed. If necessary, I grant permission to have my child transported to the nearest hospital, and I give my permission for the hospital to arrange such emergency treatment as may be needed The information provided on this form is true, to the best of my knowledge, and I give permission for my child to be examined by the hospital's physician. 
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Date *
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Parent/Guardian Signature:  I consent for my child to be given Tylenol, Ibuprofen (Advil), or Benadryl, or topical Neosporin, if necessary (You may indicate below any medications for which you do not want to give consent.) Medication dosing will be as per package dosing instructions It is noted that some students routinely take higher doses of ibuprofen; however, no more than 400mg of ibuprofen (2 tablets) will be given by the band medical personnel unless we receive a written prescription by a health care provider for higher dosing.
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Date *
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I do not give consent for these items listed above, type any that apply: Tylenol, Ibuprofen (Advil), or Benadryl, or topical Neosporin
 *
Required
Are there any additional over-the-counter medicines that you would like to provide to the nurse for your child to take? What is the medicine and dosage? 

You will be contacted prior to the start of the season by the Medical Team leader with information on how to get the medicine to the medical team.
 *
My child has permission to apply their own sunscreen. *
History: Type Yes or No. Explain any "yes" answers
Is student under a physician's care for a medical problem or condition? *
Has student had surgery/operations/hospitalizations within the last 5 years? *
Has student had any injury of muscle, bone, ligament, tendon, or joint? *
Has student had any shoulder pain or knee trouble? *
Does student have a history of fainting, migraines, seizures, convulsions? *
Does student have allergies? If so do they carry an Epi-Pen? *
Does student have asthma? If so do they carry an Inhaler? *
Is student taking any medications? If yes, please include the name of the medicine and the reason for taking it, including over-the-counter medications. *
Please list any additional comments or concerns not covered above. *
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