Cambridge Band Medical Information Form

Student Details & Medical History

Cambridge High School Band
In the unlikely event your child requires first aid or emergency care, this form is to enable the first responder to have all appropriate information in order to be able to provide aid in a safe and efficient manner. The information provided will only be accessed by the Band coaches, medical personnel, and lead chaperone for our off campus experiences. The information will be stored in a secure manner and will only be shared with appropriate emergency responders if and when required.
Upload Student Photo (recent photo please)*

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Student Name*

First NameLast Name
Student Birth Date*

MonthDayYear
Gender*

MaleFemaleNon-BinaryOther
Parent/Guardian Name*

First NameLast Name
Relationship to child*

MotherFatherGuardianOther
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency contact Email *
example@example.com

Student Insurance Information*

	Enter Information Below
Insurance Provider
Company Number
Effective Date
Policy Number

Insurance Card Front (Photograph Upload)

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Insurance Card Back (Photograph Upload)

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Has the student had in the past or does the player currently have any of the following: (check any that apply)*

AnemiaAsthmaDiabetesEpilepsy/SeizuresCoeliacs DiseaseFainting SpellsHeart DiseaseHeart AttackHigh Blood PressureKidney DiseaseLiver DiseaseNeurological DisordersBleeding DisordersLung DiseaseNoneOther
If you answered yes to any of the above, please provide details.
If asthma was selected does the student have an inhaler, and what medication is in your inhaler, what is the recommended dose for a mild and for a severe attack. (A separate form (SHS-2) found on page 3 will need to be completed and on file)
You agree to ensure that the appropriate asthma medication is brought with the player and provided to band director prior to all training, games and activities, otherwise the student will be unable to participate.

Yes
Please list any previous injuries, approximate dates, and whether or not it is still a problem.
Does the student suffer with any allergy to any medication such as (select all that apply)*

NoneIbuprofenAspirinOther non steroidal anti inflammatoryPenicillins and related antibioticsNon-penicillinsLatexOther
Does the student suffer with any other allergies such as (select all that apply)*

NoneNuts (any)EggsFishShellfishWheatGlutenSoyCows milkLactose intoleranceOther
If yes, please provide details including emergency medicines such as an Autoinjector (epinephrine) and application. (A separate form (SHS-2) found on page 3 will need to be completed and on file)
If an auto-injector is required please confirm that you will provide a device to accompany the student at each training session, event and team participation activity, (if the device is not provided participation will not be allowed and you will be asked to collect your child)*

YesNot applicable
Please list any other medications, prescription or non-prescription, that the student takes regularly. (A separate form (SHS-1) found on page 3 will need to be completed and on file)
Please include multivitamins, nutritional supplements, naturopathic medications, etc.
If yes please provide details
Has your student ever (to your knowledge) had a concussion/concussions?*

YesNo
Are your student's pupils the same size?

YesNo
If your student has had a concussion or concussions, please list the date(s) and circumstance(s) as accurately as possible.
Do you consent to have this information shared with the band director, lead chaperone, coaches, and if necessary, on-field medical personnel, Paramedics or other first responders, or hospital staff?*

YesNo (if no then the student will not be able to participate)
Please share any other details you feel are relevant.
Does your student have a family history of cardiac conditions, heart disease or stroke?*

YesNo
Please continue to the next page for Blanket Transportation Authorization.

FCS Transportation Release Form
Since your student will be transported between school sites, events, activities during and after the school day, please complete the following form.

I agree to hold Fulton County Board of Education harmless in the event of injury to
student's name* , including any property damage while the student is driving or being driven to or from a school site and/or to school-related events, activities, or sites after school hours in a vehicle other than that provided by Fulton County Board of Education.

In addition, I agree not to assert against the Fulton County Board of Education, all current, former and future members of the School Board of the Fulton County Board of Education, all current, former and future employees and/or volunteers of the Fulton County Board of Education, and their heirs, executors, administrators, successors, and assigns, in any court of law, any claim or claims that the student and/or parent or legal guardian had, now have, or may have in the future, whether known or unknown, based on any injuries sustained by the student while being so transported.

I have read the above agreement, and voluntarily sign the release and waiver of liability, and further agree that
no oral representations, statements or inducements apart from the foregoing written agreement have been made.
Parent/Guardian Initials*

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Please continue to the Fulton County Schools

SHS 1 (Authorization to give medication form)

AND

SHS 2 (Authorization for student to carry form)

SHS 1 and SHS 2 Forms

Medicine Authorization Forms
SHS 1 - AUTHORIZATION TO GIVE MEDICATION AT SCHOOL

The SHS 1 Form authorizes school personnel to administer perscription medication to students while the students are under our guardianship.

***We will only need this form to be completed and turned in WITH your child's medication FOR OVERNIGHT TRIPS ONLY. Please do not complete this form now. I have provided the link below so that families who have students whom take medicine outside of school hours can be prepared with this documentation when we get to our first overnight trip. Please download and review this form below if your student takes perscription medication outside of school. Once again...please DO NOT COMPLETE this form now, as we will need a hard copy of this form to accompany your child's medication for our overnight trip experiences.

SHS - 1 Form (Do Not Complete - Only Download)
SHS 2 - Authorization for Students to Carry a Prescription Inhaler, Epinephrine, Insulin, or Other Approved Medication*

The SHS 2 Form authorizes students to carry life saving medicine such as inhalers, insulin, or epinephrine in case of medical emergency due to an allergice reaction.

***This form is to be completed and turned in to the Cambridge High School nurse. Please download the form at the link below, complete, and snap a picture of this completed medical form and UPLOAD the form to the link below. The completed physical document MUST be turned in to the Cambridge High School nurse at the beginning of school.

In the past, Parents/Guardians have given me extra inhalers, or Epi Pens, or life saving medicine to have on hand JUST IN CASE a student has misplaced, or lost their own. This is something that I recommend that all individuals do though not required. Download the form below, complete the document, scan/snap a picture and submit to this form, and then bring the physical copy in to the Cambridge High School nurse the first week of school.

SHS - 2 Form (Download - Complete - Upload)
Upload SHS-2 Form Here (NOT SHS-1 Form)

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Physical Examination Form

Required for ALL STUDENTS
Physical Health History/Examination Form: To be completed by a Physician

Students in the Cambridge High School Marching Band will receive PE credit for participating in this athletic, outdoor, varisty level activity. As such, physical examinations are a requirement for all members of the marching band program. Physical examinations MUST be on file prior to band camp. These must be up to date and done on an annual basis. Families should NOT upload a previous physical document from past years. Please download the document below, scan/snap a picture, and UPLOAD to this form.

FAQ:

-"Can I upload my student's physical if they received the physical in November of 2024" Yes, it is okay to upload your student's physical if your student had the physical completed in November of 2024. This physical will last the entire Marching Season and is permitted.

-"I have already gotten my student's physical complete, but did not use the form you are providing below. Is this okay?" Yes, you can utilize a different physical form provided by your physician.

-"We have our physical scheduled for August 9th. Is it okay for our student to participate" This depends. If your student's prior physical was completed on August 9th, 2024 and you submit this physical the student is eligible to participate UNITL the previous year physical expire. Proceed with caution.

Students cannot participate without a physical, or insurance informatin on file and will be benched until the information is complete. Please download the document below, have a physician complete the information, and UPLOAD the physical form to this form. KEEP the paper copy for your records.

FCS Physical Examination Form (Download - Complete - Upload Below)
Upload Physical HERE:*

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We/I understand that per The Georgia High School Association a Pre-participation Physical evaluation must be performed by a physician to medically screen each student who participates in the interscholastic athletic programs of the Fulton County School District. We/I understand that a basic medical screening (the required physical exam) is general in nature and limited in scope and does not indicate or assure me/us that my/our child is completely free from impairments. If I/we wish for a more detailed physical exam to be performed upon my/our child then it is my/our responsibility to arrange and to pay for such an exam. If this more detailed exam is performed, it is my/our responsibility to notify the Fulton County School District, and it’s appropriate employees, of any potential medical problems uncovered by any physical exam given to my/our child other than the general physical required by the school system for athletic participation. I agree to fully waive any and all claims of whatever nature, fully and finally, now and forever, for my/our child, for myself, my estate, my heirs, my administrators, my executors, my assignees, my agents, my successors, and for all members of my family, and to indemnify, release, defend, exonerate, discharge and hold harmless all current, former and future members of the School Board of the Fulton County Board of Education, all current, former and future employees of the Fulton County Board of Education, their schools, their trustees, officers, Board of Education, agents, coaches, athletic trainers, physicians, volunteers, and any other practitioner of the healing arts (an “Indemnified Party”) from any and all liability, personal or property damages, claims, causes of action or demands brought against the Fulton County School District or indemnified party arising out of any injuries to my/our child or to his or her property or losses of any kind which may result from or in connection with his or her participation in any activity related to the interscholastic athletic programs provided by the Fulton County School District.
Privacy Notice

HIPAA Notice
The health information that you have provided is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use or disclose your student's PHI (Personal Health Information) only in a manner consistent with the HIPAA Privacy Rule. Under HIPAA, we are permitted to use and disclose PHI for treatment, payment and healthcare operations in accordance with the HIPAA Privacy rule; subject, however, to such use or disclosure inluding only the minimum information necessary for the stated purpose and disclosure being limited to those persons with a legitimate need to know or possess the PHI for healthcare operations, functions, or purposes.
Parent/Guardian Signature*

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Student Details & Medical History

FCS Transportation Release Form

SHS 1 and SHS 2 Forms

Physical Examination Form

Privacy Notice