Band Camp Health Form
Student's First Name: *
Student's Last Name *
If you are in Color Guard, please type "Color Guard" in the box below.
If you are unsure of your instrument, please type "N/A" or "Unknown" in the box below.
If you are in Drumline or Pit, please type "Percussion" in the box below.
Instrument: *
Grade (In Fall) *
Home Address: *
City/Zip Code: *
Parent/Guardian Full Name: *
Add'l Parent/Guardian Full Name (optional):
Home Phone (optional):
Work Phone (optional):
Parent/Guardian Cell Phone: *
Add'l Parent/Guardian Cell Phone (optional):
Email Address Parent/Guardian *
Email Address Add'l Parent/Guardian (optional)
Student's Date of Birth: *
Student's Cell Phone (Optional)
If unable to contact parents, please contact:
Name: *
Relationship to Student: *
Phone: *
Physician's Name: *
Physician's Phone: *
Insurance Company: *
Policy Number: *
Please copy the front AND back of your insurance card and email it to (pictures are acceptable as long as it is clear enough for us to read)
List any special medical conditions or needs:
Is your student taking any medications? *
If you answered "yes" above, please list the medication(s), times, and dosage:
Does your student have asthma/allergies (including food allergies)? *
If you answered "yes" above, please list the allergens below:
Is your child on a special diet? *
If you answered "yes" above, please list the dietary needs:
I give permission to have the following medication(s) administered to my child: *
By typing your name below, you are confirming and agreeing with all information on this sheet.
Parent Signature *
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