Microsoft word - registration_mail_forms.doc

Medical Information
Dowling Catholic High School
Instrumental Music Department
Student name: ___________________________________ Grade: _________ Birth date: ________________
Address: ________________________________________ Home phone: ______________________________
Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: _________
Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: __________
Relative other than those listed above or an emergency contact:
Name: ________________________________ Relationship: _____________ Phone: ______________________
Personal physician: _____________________________________ Phone: _______________________________
Personal dentist: ________________________________________ Phone ______________________________
Insurance information
Health Insurance: ___________________________________ Policy # ________________________________
Policy holder: _______________________________________ Policy holder birth date: __________________
Medical History
Past or present major disease, serious illness, or injury? No___ Yes___ (specify below)
Illness, disease, injury: _________________________________________________________ Year: ________
____Allergy (specify) ______ Contact Lenses
______Kidney Problems
Food__________________ ______ Dental problems _______ Seizures
Medication_____________ ______ Diabetes _______ Sleep walking
Environmental: _________ ______ Fainting _______ Headaches
____ Asthma ______ Heart condition _______ Surgery
____ Bleeding disorder ______ High blood pressure _______ Other
Explain items checked:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Any condition that may require special care, education, or diet:
___________________________________________________________________________________________
___________________________________________________________________________________________

Please return this form by July 15, 2010
________________________________
(Student’s Name)
Release

If parents and authorized physician or dentist cannot be reached at the time of emergency and if immediate
treatment is urgent in the perception of school authorities, I request, authorize, and will be responsible for
necessary emergency medical care. Our physician or dentist may be contacted and is authorized to release
requested information. I understand that the chaperones will endeavor to safeguard the health and safety
of each student but will, in no way, be held responsible in case of accident or illness.
_________________
__________________________________________________________
Parent/Guardian (Must be signed)
Over-the-counter Medications

Please note, we cannot be responsible for medications given to your student by another student. I authorize
chaperones to administer over-the-counter medications as directed in the event of a minor illness (e.g.,
Tylenol, Ibuprofen, Imodium, Dramamine, Benadryl, cold medications or, Antacids). Yes__________
No_______ Exceptions______________________________________________________________________

_________
_________________________________________________________
Parent/Guardian (Must be signed)
Authorization to Administer Medication
This must be signed by a parent/guardian to authorize administration of any medication being sent for the
student. Medications must be in original labeled containers. Students will be allowed to self-administer
asthma inhalers and eye medications. List all medications and non-prescription items such as vitamins and
herbal supplements:

Medication
No. of doses/day
No. of Days
_________
_________ ______________ ___________ ________
_________ _________
______________ ___________
________
_________
_________
______________ ___________ ________
I request the prescribed medication to be administered according to the above written directions.
________________
__________________________________________________________
Parent/Guardian
Please return this form by July 15, 2010

Source: http://dchsband.org/docs/2010/medical_concent_form.pdf