2025 Kent City Band Camp Medical Form

Medical Form

Fill out your medical information carefully
Student Name

First NameLast Name
Student Cell/Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Personal Email
example@example.com
T-Shirt Size
Parent/Guardian #1 Name

First NameLast Name
Parent Cell/Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Parent/Guardian #2 Name

First NameLast Name
Parent Cell/Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
In Case of Emergency - Non-Parent Emergency Contact
If, in the event of medical or other emergency, and a parent/guardian is unable to be reached by telephone numbers listed, I authorize the Director/Boosters to try and reach the parent through the emergency number listed below.
Name

First NameLast Name
Relationship to Student
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
General Medical History
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?

MonthDayYear
Date
YesNo
FoodMedicationEnvironmental
Please list and explain any allergies
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
YesNo
List any medication taken regularly, dosage and instructions:
I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure.
Medical insurance details
Name of Insurance Company:
Name of Policy Holder
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Policy Number:
Family Doctor Name
Family Doctor Phone Number
Please put all prescription meds in a clear ziplock bag that is labeled. Please check inhalers and epi-pens in at check-in, but then have the students keep them on hand.

Any non-prescription meds that the students need should be handled the same way.

Non-Emergency Treatment Consent

In the event of a non-emergency medical situation, the undersigned hereby authorizes Kent City Band Staff/Boosters to administer over the counter meds with the printed instructions for medication.
Parent Printed Name
Parent Signature

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Date

MonthDayYear
Date
Emergency Treatment Consent - Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Kent City Band and its affiliates including Directors, Staff, and Booster Board to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the date signed for one year. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Student's Name
Parent Printed Name
Parent Signature

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Date

MonthDayYear
Date
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