Marching Band Health Form (Side A)

Below is the Health Form (Side A) or download the form.
Please return this form at your uniform fitting or bring it to a Wednesday ngiht (optional) rehearsal. All forms need to be in my office no later than July 20, 2011.
Thank You for taking care of this detail.
Mr. B
Alvirne High School Music Department
Gerry Bastien, District Music Coordinator
200 Derry Rd
Hudson, NH 03051
Tel 886-1265 Email: gbastien@alvirnehs.org


Please PRINT or TYPE the following information – Thank You

Student Name: ________________________________________DOB:__________

Parent/Guardian: ________________________________________

Home Address (no PO Box, Please!)_______________________________________________

Home Phone#: _______________ Cell Phone# : _______________ Work Phone # _________

IN CASE OF EMERGENCY- - PLEASE NOTIFY (Other than parents)

Name: ___________________________________________Relationship__________________

Home Address: ___________________________

Home Phone #_______________ Cell Phone#: _______________Work Phone#_____________


Health History

Family Physician:_____________________________________________Tel # ___________


Are there any illnesses or conditions for which this child is currently receiving treatment we need to be aware of?
Yes____ No_____
Please describe
Does you child have any allergies to food, medication, bees? Yes_____ No______

Reaction to what?________________________________________

Type of reaction and severity?______________________________

Does your child carry an Epi-Pen? Yes____ No______

Date of last Tetanus Immunization: ________________________________
_________________________________________________________________________________
In case of a medical emergency, I hereby authorize any licensed physician, hospital, clinic or other medical facility to hospitalize and secure treatment for my child as named above.
Heath Insurance Co: __________________________________Policy No: ____________________
Signature of Parent/Guardian___________________________________________________
DATE: _______________________
NO STUDENT WILL BE ALLOWED TO PARTICIPATE WITHOUT THIS FORM PROPERLY COMPLETED AND RETURNED.
PLEASE FILL OUT BACK OF THIS SHEET (Side B) .