Online Medical Form

Student Name: *

First Name Last Name
DATE OF BIRTH: *

- Month - Day Year
Date

ADDRESS: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

STUDENT'S E-MAIL *
STUDENT'S PRIMARY PHONE #: *
STUDENT'S PRIMARY PHONE TYPE: *

HOME WORK CELL
CAN WE TEXT YOU INFORMATION WITH THIS NUMBER? *

YES NO
STUDENT'S SECONDARY PHONE #:
STUDENT'S SECONDARY PHONE TYPE:

HOME WORK CELL
CAN WE TEXT YOU INFORMATION WITH THIS NUMBER? *

YES NO
WHAT ENSEMBLE(S) ARE YOU IN? *

CONCERT BAND INDOOR DRUMLINE JAZZ BAND MARCHING BAND STRING ENSEMBLE ORCHESTRA WIND ENSEMBLE
WHAT INSTRUMENT(S) DO YOU PLAY FOR THE ENSEMBLES LISTED ABOVE? *
GRADUATING YEAR *
PARENT OR CUSTODIAN 1 NAME: *

First Name Last Name
PARENT OR CUSTODIAN 1 E-MAIL *
PARENT OR CUSTODIAN 1 PRIMARY PHONE #: *
PARENT OR CUSTODIAN 1 PRIMARY PHONE TYPE: *

HOME WORK CELL
CAN WE TEXT YOU INFORMATION WITH THIS NUMBER? *

YES NO
PARENT OR CUSTODIAN 1 SECONDARY PHONE #:
PARENT OR CUSTODIAN 1 SECONDARY PHONE TYPE:

HOME WORK CELL
CAN WE TEXT YOU INFORMATION WITH THIS NUMBER? *

YES NO
PARENT OR CUSTODIAN 2 NAME:

First Name Last Name
PARENT OR CUSTODIAN 2 E-MAIL
PARENT OR CUSTODIAN 2 PRIMARY PHONE #:
PARENT OR CUSTODIAN 2 PRIMARY PHONE TYPE:

HOME WORK CELL
CAN WE TEXT YOU INFORMATION WITH THIS NUMBER? *

YES NO
PARENT OR CUSTODIAN 2 SECONDARY PHONE #:
PARENT OR CUSTODIAN 2 SECONDARY PHONE TYPE:

HOME WORK CELL
CAN WE TEXT YOU INFORMATION WITH THIS NUMBER? *

YES NO
EMERGENCY CONTACT (IN ADDITION TO PARENT OR CUSTODIAN)
EMERGENCY CONTACT NAME: *

First Name Last Name
EMERGENCY CONTACT PHONE #: *
RELATIONSHIP TO STUDENT: *
⭐ REQUIRED INFO -- MUST BE FILLED IN COMPLETELY!!! ⭐

⭐ PLEASE UPLOAD A COPY (PDF OR JPEG ONLY) OF STUDENT’S INSURANCE CARD (FRONT ONLY)!!! ⭐
Browse Files

Cancel of
Physician or Practice Name: *
Phone #: *
Insurance Company: *
Policy Holder *
Policy ID #: *
Group #: *
If there is no Group # on this card, please type "NA" in this field.
By choosing the "ACCEPT" option on this medical form, I give my permission for my child to receive the following medications at the recommended dosage on the label, should a need arise. If you choose the "DO NOT ACCEPT" option, then the staff or volunteer parents will not be permitted to give your child any of these medications, if needed. *

ACCEPT DO NOT ACCEPT
PLEASE SELECT "YES" or "NO" TO THE FOLLOWING MEDICATIONS
Tylenol

YES NO
Ibuprofen

YES NO
Pepto Bismol

YES NO
Benadryl

YES NO
Imodium

YES NO
Antacid Tablets/Liquid

YES NO
PLEASE BE SURE TO UPDATE ANY OR ALL INFORMATION ON THIS FORM IF ANYTHING CHANGES. THIS INCLUDES:
- INSURANCE INFORMATION
- MEDICATIONS
- HEALTH ISSUES
DOES YOUR CHILD NEED TO TAKE ANY MEDICATIONS ON A REGULAR OR AS NEEDED BASIS? *

YES NO
IF MEDICATIONS ARE TAKEN ON A REGULAR BASIS, FILL OUT THE SECTION BELOW (INCLUDE INHALERS):
DRUG:
DOSAGE:
REASON:
DRUG:
DOSAGE:
REASON:
DRUG:
DOSAGE:
REASON:
IF MEDICATIONS ARE TAKEN ON AN AS NEEDED BASIS, FILL OUT THE SECTION BELOW:
DRUG:
DOSAGE:
REASON:
DRUG:
DOSAGE:
REASON:
REASON:
DOSAGE:
REASON:
⭐ REQUIRED INFO--PLEASE FILL OUT COMPLETELY ⭐
Does your child have any allergies (if "YES", please provide the information below)? *

YES NO
Allergic to:
Reaction:
Allergic to:
Reaction:
Does your child require the use of an epi-pen for any severe allergies? *

YES NO
If yes to above question, does your child know how to use and is able to self-administer an epi-pen? *

YES NO
If your child has a severe allergy or seasonal allergies that might require the need of an epi-pen or medication(s) to treat symptoms, please send epi-pen or medication(s) with your child.
Does your child have any medical issues we should be aware of? *

YES NO
If yes, please list the issues here.
Please List anything else you want to share:
If you have any questions or problems completing this form, please let us know at upperdarbyband@gmail.com!
Please consider making a monetary donation to the Home and School Association.

Your involvement and financial commitment will enable us to reach our goals this year.
Please feel free to email us with any questions or ideas you may have: upper.darby.home.school@gmail.com
By choosing to "ACCEPT", you as the parent/guardian hereby authorize any necessary medical treatment for student while participating with any Upper Darby High School Instrumental Music Ensemble (Marching Band, Jazz Band, Concert Band, Wind Ensemble, Indoor Drumline, Orchestra, and String Ensemble). I understand that I am responsible for payment of all charges incurred during medical treatment that may include, but is not limited to physician fees, hospital/emergency room fees, medications or ambulance costs. I hereby verify that the information given above is true, accurate and complete. *

ACCEPT
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⭐ REQUIRED INFO -- MUST BE FILLED IN COMPLETELY!!! ⭐