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Microsoft word - 2013_2014bandmedinfoform.docm

Health and Permission Form for the 2013 – 2014 Davison School Year T-Shirt Size____
STUDENT NAME _____________________________________________ ______ /______ /______
PARENT OR LEGAL GUARDIAN: NAME(S)_____________________________________________ HOME PHONE _________________ ADDRESS ____________________________________________ WORK PHONE _________________ 1st CELL PHONE ______________________ 2nd CELL PHONE _______________________ MEDICAL INSURANCE CARRIER ______________________________ I.D. # __________________ ALTERNATIVE EMERGENCY CONTACT: NAME________________________________________________ PHONE _______________________ RELATIONSHIP TO STUDENT ___________________________________________________________ NAME________________________________________________ PHONE _______________________ RELATIONSHIP TO STUDENT _________________________________________________________ HEALTH HISTORY (please check if applies) PLEASE LIST CURRENT MEDICATIONS
AND DOSAGE STUDENT IS TAKING
___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Date of last Tetanus shot ______ / _______ YES______ NO_______ (If yes please explain on back page) ALLERGIC TO INSECT STINGS YES______ NO_______ (If yes please explain on back page) OTHER ALLERGIC REACTIONS YES______ NO_______ (If yes please explain on back page) (continued on back)
Please explain any checked areas from page 1 or other health factors that would restrict the student from participating in any activity. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ PERMISSION TO ADMINISTER MEDICATION
I give permission for any chaperon to administer the following to my student. If no medication is checked, none will be given. ____ANTACID ____Dramamine _____ ANTI-DIARRHEAL _____ANTIHISTAMINE/SINUS ____ ALEVE (naproxen) ____TYLENOL (acetaminophen) ____MOTRIN (ibuprofen) PRESCRIPTION MEDICATION
A Davison Community Schools “Authorization to Administer Medication” form must be filled out by parent
and physician for all prescriptions medications. Students may self-carry and self-administer prescription
medications, except controlled substances, with physician authorization. All controlled substances, i.e. ADD
and ADHD medications, must be kept and administered by a Davison Schools employee.
This health history is correct to the best of my knowledge. The student listed has permission to engage in all choral/instrumental music activities for the 2013 - 2014 school year unless otherwise noted on this form. I hereby grant permission to authorize any medical treatment as deemed necessary at my expense for my son/daughter/ward’s participation in the choral/instrumental music program for the 2013 – 2014 school year. ____________________________________________________ SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE

Source: http://www.dbob.org/documents/2013_2014BandMedInfoForm.pdf