Band Student Health Form printable pdf download

STAFF USE ONLY

DUE PRIOR TO PARTICIPATION IN ANY

__Health Problems

REHEARSAL OR PERFORMANCE

__Allergies

UNIVERSITY HIGH SCHOOL

BAND STUDENT HEALTH FORM

1. Student’s Name: _____________________________________________________________________________

(LAST)

(FIRST)

(MIDDLE)

2. Date of Birth: __________/__________/__________ 3. Home Phone Number: ___________________________

4. Address_____________________________________________________________________________________

(STREET

______________________________________________________________________________________________

(CITY)

(STATE)

(ZIP)

5. Parent/Guardian Name: ________________________________________________________________________

6. Parent/Guardian E-mail: ________________________________________________________________________

7. Parent/Guardian Employer: _____________________________________________________________________

8. Parent/Guardian work and/or cell Phone: __________________________ (w) _________________________ (c)

9. Emergency contact if a parent/guardian cannot be reached: ________________________________________

(NAME)

__________________________________

(PHONE NUMBER)

10. Does student have insurance through parent employer? __________Yes __________No

11. If yes, name of insurance company: ____________________________________________________________

12. Policy number: ______________________________________________________________________________

13. Student’s physician: _______________________________14. Physician’s phone number: _______________

15. Health History: (check all that apply)

16. Allergies: (check all that apply)

___Diabetes

___Medication (Specify) ________________________

___Orthopedic Problems

____________________________________________

___Asthma

___Food (Specify) ____________________________

___Epilepsy

____________________________________________

___Cardiac Problems

___Insects (Specify)____________________________

___Other (Specify) ____________________ ___Latex ____________________________________

________________________________

17. Medications: At home ____________________________________________________________________

At School __________________________________________________________________

Remember: All medication, including over the counter medication requires a Dr. Order

18. Has student had a tetanus shot current within six years? ________Yes ________No

19. Do you know of any health factor that makes it advisable for your child to follow a limited program of

physical activity or from participating in any activities? ________Yes ______ No

If yes, please explain: ________________________________________________________________________

I give permission to the physician or hospital to secure proper treatment for and to order medications, injections,

anesthesia or surgery for my child as named above.

(PARENT/GUARDIAN SIGNATURE)

(DATE)

UHSBAND.NET

Band Student Health Form

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