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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
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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.
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