OLENTANGY BAND HEALTH FORM 2007

1. STUDENT’S NAME______________________________________________

2. ADDRESS____________________________________________________

3. HOME PHONE__________________________________

4. DAYTIME PARENT’S PHONE _________________________________________or____________________

5. ALLERGIES/MEDICAL CONDITIONS __________________________________

______________________________________________________________

6. MEDICATIONS/TREATMENT FOR ABOVE ______________________________________________________________

_______________________________________________________________

7. ANY OTHERS CONDITIONS THAT WOULD IMPACT ON YOUR CHILD’S PARTICIPATION IN BAND CAMP AND MARCHING BAND?

8. INSURANCE CO. NAME___________________________________

9. POLICY NUMBER________________________________

10. PERSON TO GET IN TOUCH WITH IN CASE OF EMERGENCY:

NAME______________________

PHONE_____________________

To the best of our ability, this information is current and correct.

STUDENT SIGNATURE________________________________________

PARENT SIGNATURE_________________________________________