2019-20 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 *
Student LAST Name *
Grade Level *
Date of Birth (MM/DD/YY) *
Home/Primary Phone Number *
Father's Name
Father's CELL Phone
Father's WORK Phone
Mother's Name
Mother's CELL Phone
Mother's WORK Phone
Alternate to notify in case of emergency (Name, Phone, Relationship) *
Health Insurance Provider *
Insurance Policy # *
Family Physician (Name, Phone) *
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.
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