SPRING HILL HIGH SCHOOL BAND

MEDICAL FORM

NAME: _____________________________________________FEMALE ( ) MALE ( )

DATE OF BIRTH: _____________SOCIAL SECURITY NUMBER ________ -______-___________

ADDRESS: _________________________________________________________________________

Street City, Zip

PARENT’S NAMES: _________________________________________________________________

HOME PHONE: _________________________WORK PHONE: ______________________________

MOTHER’S CELL PHONE: ___________________ DAD’S CELL PHONE: _____________________

STUDENT’S CELL PHONE: ____________________________

FAMILY DOCTOR: ____________________________DR. PHONE #:___________________

Are you presently on medication? Yes ( ) No ( ) If yes please list:

_____________________________________________________________________________

____________________________________________________________________________

Do you wear contact lenses? Yes ( ) No ( )

List any allergy and/or medical condition (i.e., fainting, dizzy spells) which at any time have caused a medical crisis. Also, please include any medical information that you think is important.

_____________________________________________________________________________________

_____________________________________________________________________________________

PARENTAL CONSENT

As parents or guardians of ___________________________, we give the directors of the Spring Hill High School Band consent for the above named student to participate in the activities of the band. We also give consent to have our son or daughter treated by a physician in case emergency medical treatment is necessary from July 16, 2008 to May 31, 2009. We understand that every effort will be made to contact our family physician and us in case an emergency arises.

________________________________ _______________________________

Parent’s Signature Date

Insurance information: ________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________