Clark Band, Jazz, Color Guard, and Percussion Emergency Card

Clark Band, Jazz, Color Guard, and Percussion Emergency Card
2024-2025 School Year
Student Name*

First NameLast Name
Student Email
example@example.com
Student ID*
Primary Phone Number*
Secondary Phone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Emergency Contact Information
Primary Emergency | Contact Name*

First NameLast Name
Primary Emergency | Phone Number*
Primary Emergency | Email*
example@example.com
Primary Emergency | What is your relationship with this person?*
Secondary Emergency | Contact Name*

First NameLast Name
Secondary Emergency | Phone Number*
Secondary Emergency | Email*
example@example.com
Secondary Emergency | What is your relationship with this person?*
Tertiary Emergency | Contact Name

First NameLast Name
Tertiary Emergency | Phone Number
Please enter a valid phone number.
Teriary Emergency | Email
example@example.com
Tertiary Emergency | What is your relationship with this person?
Medical Information
Student Date of Birth*

MonthDayYear
Date
Date of Last Tetanus Booster

MonthDayYear
Date
Primary Insurance Company*
Primary Policy Number*
Primary Group Number*
Secondary Insurance Company (If applicable)
Secondary Policy Number
Secondary Group Number
Physician Name*

First NameLast Name
Physician Primary Phone Number*
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Please list any of the following conditions, if applicable: medication allergies, food allergies, or chronic health concerns.
Contact Lens?*

YesNo
Is your child presently taking any medication(s)? If so please list them here:
Asthma?*

YesNo
Diabetic?*

YesNo
If you are diabetic,

I am Type 1I am Type 2The school nurse IS aware I am diabeticThe school nurse IS NOT aware I am diabetic
Inhaler?*

YesNo
Inhaler Type
My son/daughter has permission to participate in the Clark Intermediate Band, Jazz, Color Guard and Percussion and can travel with his/her ensemble(s) for performances and competitions during the upcoming school year. Should it be necessary for my child to have medical treatment while participating with the instrumental music program, or on a trip, and if the District is unable to contact me, I hereby authorize Clovis Unified School District personnel to use their judgment in obtaining medical services for my child. I understand that my child must have medical insurance that provides at least $1,500.00 accidental injury coverage.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Should be Empty:

Clark Band, Jazz, Color Guard, and Percussion Emergency Card

2024-2025 School Year

Emergency Contact Information

Medical Information