Burke High School Band

Student Name *

Student Birthday *

Student Age *

Student Email *

Student Address *

Parent Name *

Parent Phone Number *

Parent Work Phone Number

Insurance Name and ID Number *

Insurance Card Front and Back *

For emergency reasons, all students must have a copy on file.

Health History (Check all that apply.) *

Diabetes

Orthopedic Problems

Asthma

Cardiac Problems

High Blood Pressure

N/A

Allergies *

Asprin

Penicillin

Sulfa

Insect stings

Tetracycline

Peanuts

Tree Nuts

Shellfish

N/A

Place a check next to the medicine that the band staff has permission to administer *

Ibuprofen

Acetaminophen

Hydrocortisone Cream

Anti-fungal Cream

Antibiotic Ointment

Upset Stomach Reliever

Benedryl

Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity or from participating in any activities? Any diet restrictions? If yes, please explain. *

Does your child take any medication? If yes, please list the medications, dosages, and when the child must take the dosages. Prescriptions must be in bottle(s). *

I give permission to a licensed physician or hospital to secure proper treatment for and to order medication, injections, anesthesia, and/or surgery for my child as named above. I also give permission to the Burke Band Boosters to administer the above name medications on a band trip or during band activities. I have read the contents of this form and agree that all information provided is correct. I will not hold Mr. McCloud, Band Booster Members, or Hospital Medical Staff responsible for follow-up care, referrals, drug reactions, or other complications from treatment. *

Burke Band Emergency Form (25-26)

Burke Band Emergency Form (25-26)

Burke Band Emergency Form (25-26)