Band Tour Medical Form - Brainerd Music Department

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Band Tour 2015 Medical Form

Student Information

* Indicates required field

Name *

First

Last

Phone Number *

Ensemble *

Wind Symphony Symphonic Band

Band the student was placed in for the 2014-15 school year.

Date of Birth (MM/DD/YYYY) *

MM/DD/YYYY

Known Allergies *

Aspirin Penicillin Sulfa Insect Stings Tetracyclin Food (Specify in other) Other

Current Medications (With Dosage) If Any *

Insurance Provider *

Medical History *

Diabetes Othopedic Problems Asthma Epilepsy Cardiac Problems Other (Specify below)

Other Medical Concerns *

Policy Number *

Parent/Guardian Information

Primary Parent/Guardian *

First

Last

Primary Parent/Guardian Phone Number *

Secondary Parent/Guardian *

First

Last

Secondary Parent/Guardian Phone Number *

Other Contact Information *

By submit ion of this form I give permission to the physician or hospital to secure proper treatment for and to order medications, injections, anesthesia, or surgery for the student as named above. If an emergency arises, I understand it might be necessary for my son/daughter to receive medical care before I can be contacted.

Submit

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Brainerd High School
702 South 5th Street
Brainerd, MN 56401
218-454-6200

Forestview Middle School
12149 Knollwood Drive
Baxter, MN 56245
218-454-6000

Brainerd Music Department | 218.454.6253 | 702 South 5th Street, Brainerd MN 56401