Greensburg salem school district

GREENSBURG SALEM SCHOOL DISTRICT
2013 – 2014 ‘GOLDEN LION’ BANDS
MEDICAL INFORMATION FORM
Please print/type all information, sign and notarize on rear of form, and return by 8/7
Note: Only NEW members need to have this form notarized!
NAME: _____________________________________ SECTION: ________________________________ ADDRESS: ______________________________________________________________________________ GRADE: _______ EMAIL (PARENT): ___________________________________________________ PARENT/GUARDIAN NAME(S): _________________________________________________________ HOME PHONE: ____________________________ WORK PHONE (1): ________________________ CELL# (PARENT): __________________________ WORK PHONE (2): ________________________ NAMES OF TWO OTHER RESPONSIBLE PEOPLE TO BE CONTACTED IN AN EMERGENCY: PHONE: ________________________________________ PHONE: ________________________________________ FAMILY DOCTOR: ____________________________ PHONE: _________________________________ MEDICAL INSURANCE COMPANY: _______________________________________________________ ID #: ______________________________ GROUP#: _________________ PLAN CODE: __________ PRE-APPROVAL NEEDED? ______ PHONE # FOR APPROVAL: _____________________________ LOCAL HOSPITAL PREFERENCE: ________________________________________________________ HEALTH CONDITIONS / CURRENT MEDICATIONS / ALLERGIES: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
The following over-the-counter medications will be in the medical kit at all times. Please circle each medication
if you permit a chaperone or staff member to dispense it according to the printed directions on the package. Ibuprofen Acetaminophen (generic for Tylenol) Dimenhydrinate (generic for Dramamine) Diphenhydramine (generic for Benadryl) Bismuth Subsalicylate (generic for Pepto-Bismol) DOES STUDENT WEAR CONTACT LENSES? _______________ TYPE: __________________________ In any sickness or injury situation where “superficial first aid” is not sufficient, trained medical personnel will be summoned. When possible, contact will be made with the parent/guardian or other responsible person before treatment occurs. If necessary, transport will be to the nearest hospital unless specified otherwise (if that is practical). These decisions are made at the discretion of the Director, Staff, and/or Chaperones who are not likely to take any I, the undersigned, understand that this activity involves strenuous physical exertion and I feel that my son/daughter is physically fit for such activities. I understand that if my son/daughter is injured during the season, a physician’s release may be required before my son/daughter is permitted to resume participation in marching band activities. I hereby grant permission for my son/daughter to participate with the Greensburg Salem High School Bands in all of their activities and to travel to all performances. I further grant permission for my son/daughter to receive emergency medical treatment as required during any organized music activity, if I cannot be contacted in advance. Parent/Guardian Signature: __________________________________________ Parent/Guardian Printed Name: ________________________________________________________________ Notary Public Signature: __________________________________________ Notary Public Printed Name: ___________________________________________________________________ * * Due to health privacy regulations, this form must be notarized in order for your child to receive care
at a medical facility. This notarized signature shall be effective as long as your child is active in the
band – notarized forms from the past shall be retained for this purpose. * *

Source: http://www.gsbands.org/medform.pdf