Online Medical Form

Student Name: *

First Name Last Name

DATE OF BIRTH: *

Date

ADDRESS: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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: *

Browse Files

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.

BEFORE you get to the medication entry options "District medication policy permits a responsible, trained student to carry and/or self-administer medication for asthma, severe allergic (anaphylactic) reaction, or diabetes on his/her person for immediate use in a life-threatening situation with written order of licensed provider, parent request, school nurse, and principal approvals."

Also, if you would like to arrange to have your child's (or your own) medication held in the band's medical bag, it must have a prescription label on it.

Here is a form that should be on file with the school in order to carry your medication.
Medication Administration Request and Consent Form

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:

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!

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

Brass, drum, major and woodwinds are required to wear band gloves.

You get one pair as part of your dues payment and additional gloves are at students cost ($6 per pair).

Gloves - Which size do you need?

SMALL MEDIUM LARGE

Total for additional gloves (which you would pay outside of your dues).:

Please Note - State if you are in brass, color guard, drum major, drumline, pit, woodwinds.

You get one Jacket as part of your dues payment first year and replacement jackets are at students costs of $60. If you don't need a new jacket, leave this section blank.

Jacket - Which size or sizes do you need?

SMALL MEDIUM LARGE X-LARGE

Total for additional shirts (which you would pay outside of your dues).:

Please Note - Two section shirts are apart of your dues payment.

Additional shirts are at students cost. Small through Extral Large are $10, 2X is $12 , 3X is $13 and 4X is $14.

Shirts - Which size do you need?

SMALL MEDIUM LARGE X-LARGE 2X-LARGE 3X-LARGE 4X-LARGE

Total for additional shirts (which you would pay outside of your dues).

Please Note - New members get one pair as part of your dues payment.

What size do you currently wear in a dress shoe or sneaker? Replacement New Shoes—Color Guard and Marching Band cost $30. If you don't need a pair of replacement shoes, leave this section blank.

Shoes - What size do you need?

Enter the message as it's shown *

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