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Student’s Last Name ______________________First Name _______________________ MI _______ Grade _____________
Date of Birth _________________________________________________
Home Phone # _____________________________ Parent(s)/Guardian(s) Cell # ________________ Parent(s)/Guardian(s) Names _________________________________________________________ Work Phone #s ____________________________________________________________________ Family Physician ______________________________ Office Phone # _______________________ Please list the name and phone number of two parties who may be called if the parent/guardian may not be reached: Name ____________________________________________ Phone # ________________________ Name ____________________________________________ Phone # ________________________
All health concerns of the above named student, past and present, which may limit physical activity, be aggravated or worsened by physical activity, and/or must be known in the treatment of illness or injury must be indicated below. All students’ medical information will be kept in strict confidence by the orchestra nurse and school district staff. Please check below if the above named student has or has had any of the following: ___Chronic knee problem ___Food allergies ___Hyperventilation ___Chronic ankle problem ___History of epilepsy ___Asthma ___Chronic back problems ___History of diabetes ___Heart related problems ___Chronic foot problems ___GI disorder/problem ___Drug allergies ___Chronic cough ___Metabolic/thyroid ___Bee sting allergy ___Other If any of the above items have been checked, please provide a complete explanation. Attach a separate page if necessary.
PLEASE LIST ALL MEDICATIONS YOUR CHILD IS CURRENTLY TAKING ON A REGULAR BASIS:
Medication __________________________________________ Dosage _______________________ When taken (time of day) ________________________ Physician Prescribing __________________ Medication __________________________________________ Dosage _______________________ When taken (time of day) ________________________ Physician Prescribing __________________ Medication __________________________________________ Dosage _______________________ When taken (time of day) ________________________ Physician Prescribing __________________ Date of student’s last tetanus shot ______________________________________________________ Medical Insurance Company _________________________________ Agreement # ______________ Insurance Company Address __________________________________________________________
Please attach a small STUDENT PHOTO.
You DO NOT need to attach a copy of your insurance card.
I give permission to the orchestra nurse to provide for my student the following OTC medications and/or treatments to be offered at the nurse’s discretion or by my direction: ___Antihistamine i.e. Benadryl ___Decongestant i.e. Sudafed ___Aleve ___Acetaminophen i.e. Tylenol ___Ibuprofen i.e. Advil/Motrin ___Tums ___Antacid i.e. Pepcid, Tagament ___Premenstrual tablet i.e. Midol ___Cough drops ___No OTC medications are to be given I understand that no OTC medications will be offered to my student if I have not given my consent no matter the degree of discomfort. I/We hereby authorize representatives of North Allegheny School District to act as my/our agent to secure medical emergency treatment for the above-named student. I/We further agree to hold the North Allegheny School District and its representatives harmless for exercising its judgment in authorizing such emergency medical treatment, and said representatives are specifically authorized to sign any required emergency hospital treatment forms on our behalf. Parent/Guardian Signature _____________________________________ Date __________________
PLEASE RETURN THIS FORM WITH A STUDENT PHOTO
TO THE ORCHESTRA DIRECTOR BY FRIDAY, SEPTEMBER 9, 2011.
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