Microsoft word - medical history 2011-2012

THE MARYLAND STATE BOYCHOIR - 2011-2012 SEASON
MEDICAL HISTORY AND AUTHORIZATION FORM

Chorister's Name: _________________________________Date of Birth:__________________
Address:______________________________________________________________________
City: ____________________________ State:_______________Zip Code:_______________
School:__________________________________
Home Phone: __________________________ Boy’s cell phone: ________________________
Parent E-mail:___________________________________ (please print clearly)

Parent/Legal Guardian Information:

Father:_____________________________ Mother:__________________________________
Address: ___________________________ Address: _________________________________
(if different from chorister's address above)
(if different from chorister's address above) ___________________________ _________________________________
Employed by: _______________________ Employed by: _____________________________
Occupation: ________________________ Occupation: ______________________________
Work Phone: _______________________ Work Phone: _____________________________
Mobile Phone: ______________________ Mobile Phone: ____________________________
In the event of an emergency, please list two (2) people other than parent or guardian who
can be contacted in case you cannot be reached:

1. ___________________________________________________________________________
name relationship telephone number
2. ____________________________________________________________________________
name relationship

Physician’s Information:
Please list all physicians responsible for your child’s medical care:
Name: ______________________________
City/State/Zip: _______________________ Health Assessment
To the best of your knowledge, does your son have a history of any problems with the following? Comment on any positive answers below. *Asthma: Send an inhaler labeled with your son’s name to each choir event. What is your son’s baseline peak flow? __________________ Is your son on maintenance medication? Yes (If yes, list below) _______ No _____
**Allergies: List allergy and reaction. Does your son carry an epi-pen? Yes _____ No ____
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Should there be any restriction or limitation to physical activity? If yes, specify nature and
duration of restriction:
______________________________________________________________________________
______________________________________________________________________________
The following medications may be administered, in the recommended dosage, to my son:

Is your son on any long-term medication? If yes, please list below:
YES _____
Is your son up to date on all immunizations? Would you like a conference with the Director to discuss your son’s specific health concerns? YES _____ Signatures
I give my permission for the adult staff to administer over-the-counter medications (as above). I also give permission for the adult staff to render first aid care in the event of minor injuries. _____________________________________________________ Parent's Signature and Date In order to enable MSB staff to deal with medical situations while your son is under our care, we ask that you sign and date the following waivers. By my signature, I state that I have completed all statements on this medical form truthfully and correctly to the best of my knowledge, information and belief. I also acknowledge that it is my sole responsibility to inform the Director or Administrator of The Maryland State Boychoir of any changes or updates to this form as it pertains to my son’s health or insurance coverage. These changes and updates will be submitted to them in writing as soon as possible when they occur. I will also see the Administrator to complete a Medication Administra-tion Form as it pertains to my son in regard to medication. I further understand that every precaution is taken to ensure my son’s health and safety; therefore, my responsibility for providing medical coverage further ensures my son’s welfare beyond the care that The Maryland State Boychoir provides. ____________________________________________ Parent's Signature and Date By my signature herein, I grant full authority to The Maryland State Boychoir, its Board of Directors, and Administrative Staff to obtain and authorize any and all medical treatment or hospitalization necessary, in my absence, in the event of an emergency, accident, or illness to my son. This authorization is granted during any function of The Maryland State Boychoir or Residential Choir Camp where my son is placed in their care. I further understand that every attempt will be made to contact and cooperate with my insurance coverage; however, in extreme emergency circumstances, any charges for medical treatment not covered by my insurance will be my financial responsibility. ______________________________________________ Parent's Signature and Date

Source: http://www.marylandstateboychoir.org/wp-content/uploads/2011/09/Medical-History-2011-2012.pdf