EVHS Choir Medical Form
(Please fill out completely.
Mrs. R must have a medical form on record for any student to participate
in all choir field trips and activities.)
Student Full
Name__________________________________________________________________
Last First Middle
Student Bithdate_______________________________Student
Social Security #____________________
(mm/dd/yy) (most
hospitals require this)
Address___________________________________________________________________________________________________________________________________________________________________
Mother’s Full name______________________________Mother’s
Employer Phone__________________
Father’s Full name_______________________________Father’s
Employer Phone__________________
Health Insurance
Company___________________________Individual#_________________________________
Insured Name_______________________________Group
#___________________________
__I am not insured.
**If you cannot be reached, please list the name and
number of the person who should be contacted.
Name__________________________________________Phone
#_______________________________
Name__________________________________________Phone#________________________________
Medical History- If you have had any of the following, please
list type and date.
Operations_____________________________________date_______________________
Hosp
italizations_________________________________date_______________________
Have you or a blood relative had any of the following,
please circle:
1.Diabetes Self/
Relative 5.Hypertension
Self/ Relative 8.Caner Self/Relative
2. Kidney Disease
Self/ Relative 6.Asthma Self/ Relative 9. Hayfever
Self Relative
3. Tuberculosis
Self/ Relative 7.
Epilepsy Self/ Relative 10.
Anemia Self/ Relative
4. Heart Disease
Self/ Relative
Are you allergic to any of the following:
____Bee Stings ___Trees ___Molds ____Pollen ___Other
____Grass
Do you have any food allergies?
Please list any medications that you are currently
taking:
Please list any medications that you are allergic to:
While on a trip will you allow Mrs. R or a designated
chaperone to give your student (if needed):
__ Extra Strength
Tylenol
__ IB Profen
__Benadryl (by mouth)
__Benadryl (
topical)
__ Dramamine
Number of pills allowed.
Extra Strength Tylenol ___1 __2 ___1-2
depending on symptoms
IB Profen ___1 __2 ___1-2
depending on symptoms
Benadryl (mouth) ___1 __2 ___1-2
depending on symptoms
Dramamine ___1/2 __1
This is to authorize any hospital or physician to render
necessary medical care to my son/daughter____________________________in the
event that I am unable to be reached by the hospital or physician. In that particular case, I consent for
Tiffany Richtarski, EVHS Choral Director, to act on my behalf in granting
permission for emergency treatment. This
authority shall be in effect as long as the above youth is in the custody of
Mrs. Richtarski.
Date:
Parent Signature
