Wakeland Band Medical Emergency Information

Wakeland Band Medical Emergency Information
Student Name*

Legal First NameLast Name
Date of Birth*

MonthDayYear
Date
Emergency Contact Name 1*
Phone*
Emergency Contact Name 2*
Phone*
Doctor & Insurance Information
Student's Primary Care Physician*
Phone*
Insurance Provider*
Insurance Phone Number*
Policy Number*
Group Number*
Medical Information
Check all that apply to the student:*

Glasses/ContactsAsthmaAllergies (list below)Medications (list below)None
List all known allergies medications special health conditions restrictions and pertinent medical information here
Medical Waiver
I, parent name* the parent/legal guardian of the student named above, hereby give my permission for the above named student to participate in all activities with the Wakeland High School Band. I will not hold Wakeland High School, the Wakeland High School staff or volunteers responsible for any injuries or accidents that occur during any Wakeland High School Band function. I give my permission for the Wakeland High School Band staff to obtain emergency medical care for my child if I cannot be reached.".
Signed*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Doctor & Insurance Information