2018-19 Band Emergency Form
If you have not had any changes since last year, you do not need to submit this form again.
Student FIRST Name *
Your answer
Student LAST Name *
Your answer
Grade Level *
Date of Birth (MM/DD/YY) *
Your answer
Home/Primary Phone Number *
Your answer
Father's Name
Your answer
Father's CELL Phone
Your answer
Father's WORK Phone
Your answer
Mother's Name
Your answer
Mother's CELL Phone
Your answer
Mother's WORK Phone
Your answer
Alternate to notify in case of emergency (Name, Phone, Relationship) *
Your answer
Health Insurance Provider *
Your answer
Insurance Policy # *
Your answer
Family Physician (Name, Phone) *
Your answer
Does the student have chronic health problems? *
If YES, please explain in Other:
Does the student have any allergies to medicines? *
If YES, please explain in Other:
Does the student have any other allergies? *
If YES, please explain in Other:
Does the student take any medications? *
If YES, please explain in Other:
Has the student had a tetanus shot in the last 10 years? *
If YES, please also list date (if known) in Other:
Has the student been hospitalized in the last 5 years? *
If YES, please explain in Other:
Please list any other pertinent health information.
Your answer
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