Band Camp Health Form
Student's First Name: *
Student's Last Name *
PLEASE NOTE:
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: *
MM
/
DD
/
YYYY
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 waverlywarriorband@gmail.com (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: *
Required
By typing your name below, you are confirming and agreeing with all information on this sheet.
Parent Signature *
Submit
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