SY 2021-2022 Etowah Band Medical Information
Please fill out the following form as completely as possible. This is to help us in the unlikely event your student requires assistance during a practice or performance.

If you have any questions, or need to update your student's information, email Mr. Long ( or the Booster Presidents (
Student First Name *
Student Last Name *
Primary Street Address *
Primary City *
Primary Zip Code *
Student Birthdate *
Student year of graduation *
Primary Parent/Guardian Name *
Primary Parent/Guardian Emergency Phone Number *
Primary Parent/Guardian Email *
Secondary Emergency Contact Name *
Secondary Emergency Contact Phone Number *
Secondary Emergency Contact Email *
Additional Emergency Contact Name
Additional Emergency Contact Phone Number
Additional Emergency Contact Email
Please list all know allergies - including medications, foods, animals, insect bites, stings, and the environment. (If none type NONE) *
Please list all know conditions - including asthma, diabetes, low blood sugar, blood pressure, heart conditions, or other conditions that may help in caring for your student in an active environment. (If none type NONE) *
Please list all medications currently being used by the student. If this list changes, please contact Mr. Long via email. (If none type NONE) *
I understand that if a parent or guardian cannot be reached, or that immediate attention is required, the EHS Band or any of its designated volunteers has my permission to seek appropriate medical attention for my child. *
By typing my First and Last name, I am confirming that all information submitted on this form is accurate and truthful to the best of my knowledge. I understand that if any of this information requires updating it is the responsibility of the Parent/Guardian to contact Mr. Long to notify him of those changes. *
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