If your child suffers from any of the following conditions, please check the appropriate box.
If you checked any boxes in the above question, please explain below.
Medications Currently Taking/Using – All Prescription and Non-Prescription ORAL medication(s) and Prescription EXTERNAL medication(s), such as, inhaler, anticonvulsive, antihistamine, antifungal, acne, insulin, Ritalin, etc. Giving medication name, date treatment prescribed and instruction(s):
Recent Surgery/Procedures/Illness (within 1 year)
Past Surgery/Procedures/Illnesses (greater than 1 year ago) that may be significant to extensive exercise or important to note in an emergency):
Is child under any medical treatment at present other than medications already listed: If yes, explain.
Is there anything else that should be called to the attention of the Band Director and staff?
Student's Physician Name:
Physician's Phone Number
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