JEFFERSON HIGH SCHOOL BAND

							                                    JEFFERSON HIGH SCHOOL BAND
    EMERGENCY CONTACT AND HEALTH FORM
                 (Both sides of the form MUST be completed and returned prior to the issuing of any uniform,
                           equipment or participation in any Jefferson High School Band activities)

PLEASE PRINT CLEARLY                                                                    Year of Graduation ______________

Last Name _______________________________________ First Name _____________________________________
Birth Date ________________________ Weight ___________ Height __________ Gender                     Male  Female
Parent or Guardian_________________________________________________ Relation _______________________
        Home Address______________________________________________ Phone # _______________________
                ___________________________________________________ Cell # _________________________
        Business Address ___________________________________________ Phone # _______________________
2nd Parent or Emergency Contact _____________________________________ Relation _______________________
        Home Address______________________________________________ Phone # _______________________
                ___________________________________________________ Cell # _________________________
        Business Address ___________________________________________ Phone # _______________________
Other Emergency Contact: _______________________________________ Home # _________________________
                                                                                  Cell # ___________________________

Student’s Doctor __________________________________________________ Phone # _______________________
        Doctor’s Address _________________________________________________________________________
Family has insurance with __________________________________________________________________________
        Policy number _____________________________________
        If group insurance, please complete: Employer’s name ____________________________________________
        Employer’s address ________________________________________________________________________

ARE THERE ANY SPECIAL SITUATIONS OR CONDITIONS WE SHOULD KNOW ABOUT?
Physical ________________________________________________________________________________________
Mental or emotional ______________________________________________________________________________
Are there any special dietary needs? __________________________________________________________________

Has the band member ever required any psychological counseling or hospitalization?             yes    no
If “YES”, explain ________________________________________________________________________________

Sleepwalking?      yes    no                   Other      yes    no       (Specify ____________________________)
Date of last tetanus shot _________________________________________

Does the student use an inhaler for asthma or other breathing condition?          no
                                                                                  yes

Does the student have skin allergies that would prevent them from using sunscreen?  yes  no
        (Students must wear sunscreen during band camp and other outdoor activities or rehearsals.)
                                              CONTINUED ON BACK 
                    HEALTH HISTORY AND MEDICATION
Health History                 Diseases                  Allergies                   Please cross off this list any medications
                                                                                     you DO NOT want student to receive
__ Frequent ear infections     __ Chicken Pox            __ Hay Fever                         Tylenol
__ Heart Defect/Disease        __ Measles                __ Poison Ivy, etc.                  Ibuprofen
__ Convulsions                 __ German Measles         __ Insect Stings                     Benadryl
__ Diabetes                    __ Mumps                  __ Penicillin                        Antacid
__ Blood/Clotting Disorders                              __ Other Drugs-specify               Throat Lozenges
__ Hypertension                                                                               Robitussin-DM
__ Mononucleosis                                         __ Other -specify                    Rhuli-Anti-Itch Gel
                                                                                              Triple Antibiotic Ointment
                                                                                              Pepto Bismol

MEDICATIONS BEING TAKEN
All medications and prescription drugs must meet the following guidelines:

The medication must be in the original container, and if the medication is a prescription, it must bear the pharmacy
       label which shows the prescription number, date filled, prescribing physician’s name, name of patient, name of
       medication, and directions for taking the medication.
All medications must be turned in to the Band Nurse during registration before departure to band camp or other
       long term trip. All medications will be stored in the infirmary and distributed by the Band Nurse as directed.

Please list ALL medications (including over the counter or nonprescription drugs) taken routinely. Bring enough
medication to last the entire duration of camp or a trip.

    This band member takes NO medication on a routine basis.
    This band member takes medications as follows:
Med # 1 _______________________________ Dosage _____________ Specific times taken each day ____________
Reason for taking ________________________________________________________________________________

Med # 2 _______________________________ Dosage _____________ Specific times taken each day ____________
Reason for taking ________________________________________________________________________________

Med # 3 _______________________________ Dosage _____________ Specific times taken each day ____________
Reason for taking ________________________________________________________________________________

Attach additional pages for more medications.

List any medications taken during the school year that the student does not take during the summer:
_______________________________________________________________________________________________
Initials of parent or guardian: _______________ Date _________________

IN CASE OF EMERGENCY I understand every effort will be made to contact me or the person (s) I have named on
this form. In the event I cannot be reached, I hereby give permission to the medical personnel selected by John P.
Lynch, Jr., Band Director, to hospitalize, secure proper treatment for, and to order injection, and / or anesthesia and / or
surgery for my child as named above.

Signature of Parent or Guardian _________________________________________ Date ____________________