North Pulaski High School Band

Medical Form

1) Student’s Name ______________________________________________________________________ Date of Birth ____/____/____

2) Address _________________________________________________________ City __________________ State ____ Zip ________

3) Student’s Social Security Number (optional)_________________________________________________________________________

4) Home Phone ________________________________________________________________________________________________

5) Parent or Guardian Name ______________________________________________________________________________________

6) Place of Employment _____________________________________________________________ Work Phone _________________

7) Insurance Company _________________________________________________ Policy Number _____________________________

8) Health History: (check)

    _____ Diabetes      _____ Orthopedic Problems          _____ Asthma           _____Epilepsy

    _____ Cardiac Problems           _____ Other (please specify)

___________________________________________________________________________________________________________

9) Allergies: (check)

    _____ Aspirin           _____ Penicillin           _____ Sulfa           _____ Insect Stings          

    _____ Other Medications or Allergies   __________________________________________________________________________

10) Do we have your permission to administer to your child?  _____ Aspirin  _____ Tylenol

11) Has your child had a current tetanus shot (within six years)?  _____ Yes  _____ No

PARENT AUTHORIZATION:  This health history is correct to the best of my knowledge.  I give permission to administer treatment and/or medication to my child.

__________________________________________________________________________________________________________

Signature of parent or guardian                                                                                                            Date