Athens Orchestras Health History Form 2018-2019 School Year
Necessary for any Fall Camp AND field trip with the Orchestras. To be filled out once a year, good for one year.
Student Name (First and Last) *
**REQUIRED
Your answer
STUDENT Cell Phone Number *
This will be viewed by Mr. Quinn for trips (including camp) and will be given to the student's chaperone IF they go on the spring trip/camp.
Your answer
Home Address (street, city, ZIP) *
**REQUIRED
Your answer
Student Birth Date *
**REQUIRED
MM
/
DD
/
YYYY
Student's Grade Level as of Fall 2018 *
Sex *
**REQUIRED
T-Shirt Size *
**REQUIRED
Parent/Guardian Name (1) *
**REQUIRED
Your answer
Parent/Guardian Cell Phone Number (1) *
**REQUIRED
Your answer
Parent/Guardian E-Mail *
**REQUIRED
Your answer
Parent/Guardian Name (2)
Your answer
Parent/Guardian Cell Phone Number (2)
Your answer
Medical Insurance Carrier *
**REQUIRED
Your answer
Family Physician *
**REQUIRED
Your answer
Physician Phone Number *
**REQUIRED
Your answer
Emergency Contact Name *
**REQUIRED
Your answer
Emergency Contact Phone Number *
**REQUIRED
Your answer
Emergency Contact Relationship *
**REQUIRED
Your answer
Health History - Check boxes if your child has had or currently has any of the following medical problems *
If your child has not or does not have any of the following, please answer "NONE"
Required
If you answered "yes" above, please explain:
ex: "My child had poison ivy twice" "My child has seasonal allergies" - SEE NEXT QUESTION
Your answer
If your child has allergies, how does he/she react?
Itching, Hives, breathing difficulty, etc.
Your answer
Any other information that will help us take care of your student?
(History of anxiety, etc.)
Your answer
Does your child take medication regularly? If yes, please list the NAME, DOSAGE, HOW OFTEN, AND REASON *
THIS INCLUDES IBUPROFEN (MOTRIN) ACETAMINOPHEN (TYLENOL) FOR HEADACHES, GROWING PAINS, ETC. If none, please say "N/A"
Your answer
We have the following medications available for your student's use, if necessary. Please check next to each medication we may administer to your child. IF NONE ARE CHECKED, NONE CAN BE GIVEN FOR ANY REASON (headache, fever, allergy, insect bites, etc.) *
**REQUIRED
Required
PARENT AUTHORIZATION AND CONSENT: by typing your name, you acknowledge the above to be true to the best of your knowledge, and the person noted may participate in all activities except as noted. *
**REQUIRED
Your answer
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