Part 1 of 3 - Aledo MS Band Medical History and General Waiver
Student Medical History
Email address *
Student First Name and Middle Initial *
Your answer
Student Last Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Parent(s)/Guardian(s) Name *
Your answer
Email of Parent/Guardian *
Your answer
Work or Cell Phone *
Your answer
Alternate Contact Name *
Your answer
Alternate Contact Phone/Cell *
Your answer
Physician Name *
Your answer
Physician Office Number *
Your answer
Insurance Company *
Your answer
Insurance Policy# *
Your answer
Insurance Phone *
Your answer
Medical History (Has your child ever experienced a medical problem associated with any of the following? Check all that apply)
Please provide specific information regarding each of the above items checked
Your answer
Please list any medications which your child takes on a regular basis. Include the medication name, dosage, and frequency
Your answer
ALLERGIES - Is your child allergic to medications? (Please list) Any other allergies? (Please list)
Your answer
Please indicate which of the below over the counter medications that you approve to be dispensed to your student at the discretion of the Band Directors or a designated chaparone.
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