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2013-2014 SBRHS WINTER PERCUSSION ENSEMBLE & COLOR GUARD HEALTH FORM
Please be sure to fill out ALL information on the form, if it does not apply, please write N/A
Student Name: _______________________________________ Section/Squad: _____________________ Grade: ____ Parent/Guardian Name: _____________________________________________________________________________ Address: ___________________________________________________ City: ____________ State ____ Zip: ______ Home Telephone: ________________________________ Business/Day Phone: _______________________________ 1. If a parent is not available in the unlikely case of an emergency, please notify: (Give two names other than parents) Name: ____________________________________________ Name: ____________________________________________ Relationship: _______________________________________ Relationship: _______________________________________ Phone: ____________________________________________ Phone: ____________________________________________ 2. Physician’s Name: ______________________________________________ Phone: _____________________________ 3. Does your son/daughter have any illness that (s)he is being treated for? (Ex. Diabetes, epilepsy, asthma) Yes _____ No _____
If yes, Indicate illness: _________________________________
(All information given is confidential.)
If asthmatic, does you son/daughter use an inhaler?
Yes _____ No _____ If yes, name of inhaler: _____________________________________________
Please be sure your son/daughter has an extra inhaler. Please instruct your son/daughter to keep the inhaler with him/her
at all times. The school nurse should be given the extra inhaler in case of loss.

4. Please list any medications your son/daughter takes on a regular basis. (Please be sure to send it with them.)
Indicate below the name of the medication and the specific times of day to be taken: Medicine: ________________________________________ Time to be taken: ________________________________ Medicine: ________________________________________ Time to be taken: ________________________________ Medicine: ________________________________________ Time to be taken: ________________________________ 5. Please indicate if your son/daughter is allergic to the following. (Yes or No)
Ibuprofen (Advil) _____ Penicillin _____ Aspirin _____ Other Drugs _________________________________________________ Food Allergy _________________________________________________________________________ If yes, please describe the type of reaction, (Hives, breathing difficulties, swelling, etc.)
________________________________________________________________________________________________________
Important: Persons allergic to bee stings must have a bee sting kit with them at all times. (Available by calling physician.)
6. If it is felt that your son/daughter should have the medication listed here, may an official chaperone administer your son/daughter
the medicine? (Yes or No) Cough syrup ______ Cold/allergy pill ______ Tylenol ______ Advil ______ Something for upset stomach ______ Dramamine ______ Other (Please indicate preference) __________________________________________________________ 7. Date of last tetanus shot: _____________________________________
8. Please indicate health insurance information: Plan: _____________________________________________________________________________
If Blue Cross/Blue Shield, indicate MA or RI ______________
ID Number: ____________________________________________
Subscriber’s name: ______________________________________ (Attach a copy of card if possible)

9. Suggestions from parents as to limitations or signs of health risks for chaperones to be aware of: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 10. Has your son/daughter been recently exposed to any contagious disease? Yes _____ No _____ If yes, what disease? ______________________________________________________________________________________ Authorization: This Health History is correct insofar as I know and the student therein described has my permission, as legal parent/guardian, to
engage in all prescribed tour activities, except as noted by me in the space provided above. In the event that I or the individuals listed above for
emergency notification cannot be reached in an “emergency”, I hereby give my permission to the physician selected by Mr. David M. Marshall to
hospitalize, secure proper treatment for and to order injections, anesthesia, or surgery for my son/daughter as named above.
Parent/Guardian Signature: ________________________________________________________ Date: _____________

Source: http://www.somersetmusic.org/PDF%20Files/Winter%20Percussion%20&%20Winter%20Color%20Guard%20PDF%20Files/2014/2013-2014%20SBRHS%20Winter%20Ensembles%20Health%20Form.pdf