Microsoft word - medical_form

PENN HILLS HIGH SCHOOL MUSIC DEPARTMENT
Medical Information/Emergency Treatment Authorization

Student Name______________________________________ Date:__________________
Sex_____ Age _____ Date of Birth _________________ Grade: __________________
Home Address_____________________________________________________________
(Street) (City, State) (Zip)
Home Phone_____________________ Parent/Guardian Cell Phone_________________
Parent/Guardian Cell Phone_________________

Parent/Guardian Name______________________________________________________
Work Phone________________________ Work Hours___________________
Parent/Guardian Name______________________________________________________
Work Phone_________________________ Work Hours___________________
Health Insurance___________________________ Subscriber_______________________
Address_______________________________ Employer________________________
_______________________________ Address_________________________
Agreement #___________________________ _________________________
Primary Care Physician_________________________ Phone_______________________
If the Band Director or Staff cannot contact either parent/guardian, please list two relatives
or friends who would have authority to advise regarding your child:

1. Name___________________________________ Relationship________________

Address________________________________ Phone_____________________________

2. Name___________________________________ Relationship_________________

Address__________________________________ Phone___________________________


If EMERGENCY TREATMENT is required, may the Band Director or Staff use their
own judgment in sending the child to the hospital or doctor most easily accessible before
the parent/guardian can be reached: YES NO
If NO, what should be done?___________________________________________________

Does the student have any allergies? (Please list medication, environmental and dietary
Allergies) __________________________________________________________________
List any medical conditions of which the Band Director or medical personnel should be
made aware (i.e. asthma, diabetes, seizures, heart conditions, mental health conditions,
etc.):_______________________________________________________________________
___________________________________________________________________________
Current Medications (please list name, dose and frequency of medication) ____________
__________________________________________________________________________________ 
__________________________________________________________________________________ 
 
Date of Last Tetanus Shot: ______________________________________
MEDICATION WILL NOT BE DISPENSED TO ANY STUDENT WITHOUT
PERMISSION FROM THE PARENT/GUARDIAN. Please review the following list of over
the counter medication and circle those medications that you will allow your student to
receive from the Band Director/Staff/Chaperones:
Tylenol

Ibuprofen
Dramamine
Antacids

__ I DO NOT WANT ANY MEDICATIONS TO BE DISPENSED TO MY CHILD
ALL MEDICAL INFORMATION WILL BE KEPT CONFIDENTIAL
It is understood that in the final disposition of an emergency case, the judgment of the
Band Director or Staff 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 the Band Director in writing.
_________________________ __________________________________________________
Print Name Signature (Parent/Guardian) Date
IF YOU ARE A RETURNING MARCHING BAND MEMBER AND YOUR
PREVIOUS MEDICAL INFORMATION HAS NOT CHANGED, THIS FORM
DOES NOT NEED NOTORIZED, JUST A SIGNATURE OF PARENT/GUARDIAN
REQUIRED.
Before me, the undersigned authority, personally appeared___________________________.
known to me or sufficiently proven to me to be the person who executed the foregoing
document. IN WITNESS WHEREOF, I have hereunto set my seal this _______ day of
__________________, 20______.
___________________________________ My commission expires:_____________________
Notary Public

Source: http://www.phsd.k12.pa.us/pdf/MBMedForm.pdf