Shiloh High School Band – General and Medical Information
** Please complete all fields accurately and completely for the safety of your child during our trip **
Student’s Name Email
Instrument Date of Birth Grade (2011-2012)
Home Phone Cell Phone
Address City Zip
Father
Home #
Or legal Guardian If different than student
Work Phone Cell Phone
Mother
Home #
Or legal Guardian If different than student
Work Phone Cell Phone
Emergency Contact
Relationship:
(If parent cannot be reached)
Phone # Cell Phone #
Any known allergies? If yes, please explain
Medical Problems?
Is student on any medication? If yes, please complete the detailed medical & Medication Information form
Date of last tetanus shot:
Please circle & initial non-prescription medications your child may take from the chaperones
Tylenol Advil Antacid Benadryl Decongestants (cold medicine)
Physician Phone
Insurance Company Name of Insured
Group/Identity# Policy #
The Shiloh High School Band Directors, school administrators, and Band Booster Association Representatives have
my permission to secure emergency medical treatment for my child should the need arise during school and band
functions.
Parent/Guardian Signature Date