Lloyd c

Lloyd C. Bird Skyhawk Band

Student Name____________________________________________________________________
Last
Age __________ Date of Birth ________________ Social Security Number ___________________ Address _________________________________________________________________________ Street & Number
Parent/Guardian Names & Address
________________________________________________________________________________
Mother’s Name
_______________________________________________________________________________________________ Mother’s Home Phone ________________________________________________________________________________ Father’s Name _______________________________________________________________________________________________ Father’s Home Phone Emergency Contact (Other than parent or guardian)
________________________________________________________________________________
Name
_______________________________________________________________________________________________ Home Phone
Student’s Doctor______________________________________________________________________________

Medical History
Does student have a Medical Treatment Plan on file with Chesterfield County Schools? ___________
If yes, a copy must be attached to this form.

Check if your student has any of the following.
Chronic Ear Infections _______
Other (specify) ______________________________________________________ Describe their conditions, reactions and treatments in space below.
________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________________________________
Surgeries, Hospitalizations or Other Serious Injuries/ Conditions Not Listed Above
________________________________________________________________________________
Date Last Tetanus Shot _______________
Lloyd C. Bird Skyhawk Band
Student Name ___________________________________________________________________
Last
Allergies
(Circle type)
Reaction
Treatment
Drug, Food, Insect sting _____________________ ____________________ ____________________________ Drug, Food, Insect sting _____________________ ____________________ ____________________________ Drug, Food, Insect sting _____________________ ____________________ ____________________________
Does student carry an “Epi Pen” or inhaler? _____________________________________________
Medications Taken
_______________________________________________________________________________________
Name
_______________________________________________________________________________________
Name
_______________________________________________________________________________________
Name
_______________________________________________________________________________________
Name
ALL MEDICATION MUST BE LEFT WITH THE DESIGNATED CHAPERONE DURING TRIPS. CHAPERONE WILL ADMINISTER MEDICATIONS LISTED ABOVE WHEN NEEDED. Check “Yes” or “No” to indicate if the student may receive over-the-counter drugs from a band parent: Over the Counter Drug
Common uses
HEALTH INSURANCE
__________________________________________________________________________________
Company
YOU ARE REQUIRED TO ATTACH A FRONT & BACK COPY OF YOUR
HEALTH INSURANCE CARD TO THIS FORM
I give permission for ______________________________(son/daughter’s name) to travel with the Lloyd C. Bird Skyhawk Band on all of the dates on the fall marching band calendar. I give my consent to have my son or daughter treated should a medical emergency arise. I understand every effort will be made to contact me should an emergency arise. Parent or Guardian Signature ________________________________ Date _______________________

Source: http://lcbirdband.org/wp-content/uploads/2012/08/2013-14-medical-form.pdf