FRANKLIN REGIONAL BAND EMERGENCY MEDICAL HEALTH FORM

SCHOOL YEAR

STUDENT NAME

AGE

SEX

BIRTHDATE

HOME ADDRESS

PHONE

FATHER’S FULL NAME

MOTHER’S FULL NAME

STEP PARENT OR GUARDIAN’S NAME

FATHER

MOTHER

STEP PARENT OR GUARDIAN

PHONE NUMBERS

WORK PHONE

CELL PHONE

Is the student currently under medical treatment?  YES NO

If yes, give the nature of the treatment and doctor’s name & phone:

Is the student taking any medication?  YES  NO

If yes, give the name of the medication, reason it is given, doctor’s name & phone:

List any ailments or allergies of your child that the school nurse or medical personnel should be made aware
 (ie epilepsy, heart condition, diabetes, allergies, etc):

DATE OF LAST TETANUS SHOT

NAME OF HEALTH INSURANCE

PHONE

ADDRESS

NAME OF GUARANTOR

AGREEMENT #

NAME OF EMPLOYER (if group insurance)

ADDRESS

PHONE

GROUP #

FIRST AID/EMERGENCY AUTHORIZATION

If the director or sponsor cannot get in touch with either parent/guardian, please list two relatives or friends who would have the authority to advise us regarding your child:

1. NAME

RELATIONSHIP TO CHILD

ADDRESS

PHONE

2. NAME

RELATIONSHIP TO CHILD

ADDRESS

PHONE

If none of the above can be reached by phone, WHAT DO YOU WISH THE DIRECTOR OR SPONSOR TO DO in case the child is sick or injured?

If EMERGENCY TREATMENT is required, may the director or sponsor use their own judgment in sending the child to a hospital or doctor most easily accessible before the parent/guardian can be reached? YES  NO

If no, name preferred hospital

preferred doctor

It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. The recommendation of the parent/guardian, as indicated above, will be respected as far as possible.

If at any time the above information must be changed, I will notify my child’s music director and/or sponsor in writing.

PLEASE ATTACH A COPY OF BOTH SIDES OF THE CHILD’S MEDICAL INSURANCE CARD(S).

___________________________________________________

Signature of parent or guardian          Date