Troy band

TROY BAND
Student Medical and Treatment Authorization Form
Student’s Name_____________________________________________Age________________ (first) (last) (m.i.) Birthdate__________________________________Male________Female__________________ Home Address__________________________________________________________________ City_____________________________________________State__________Zip Code________ Home Phone Number____________________________________________________________ Mother/Guardian________________________________________________________________ Work Phone_____________________________________ Cell Phone______________________________________ Pager Number___________________________________ Father/Guardian________________________________________________________________ Work Phone_____________________________________ Cell Phone______________________________________ Page Number____________________________________
Name of Emergency Contact OTHER THAN PARTENT:______________________________
Relationship to student_____________________________ Phone Number____________________________________
Name of Secondary Emergency Contact OTHER THAN PARENT:______________________
Relationship to student_____________________________ Phone Number____________________________________
Family Doctor____________________________ Office Phone__________________________
Family Dentist____________________________ Office Phone__________________________
Orthodontist______________________________ Office Phone__________________________
Health Insurance Carrier________________________________________________________
Policy/ID #_______________________________ Policy/Plan#___________________________
Policy Holder’s Name____________________________________________________________
Health Insurance Phone #_________________________________________________________
Do any pre-certification, notification, or other requirements exist with respect to the health
insurance of the student? If so specify:______________________________________________
______________________________________________________________________________
Current Medications: __________________________________________________________
______________________________________________________________________________
General: Does student have: ( if “yes” explain)
___Yes ___No Allergies (i.e. food, drug)?___________________________________________
___Yes ___No Asthma?_________________________________________________________
___Yes ___No Heart Condition?___________________________________________________
___Yes ___No Diabetic?_________________________________________________________
___Yes ___No Vision Impairment?_________________________________________________
___Yes ___No Hearing Impairment?________________________________________________
___Yes ___No Other?____________________________________________________________
Is student subject to: (if “yes” explain)
___Yes ___No Headaches(especially migraines)?_____________________________________
___Yes ___No Seizures?________________________________________________________
___Yes ___No Motion Sickness?__________________________________________________
___Yes ___No Fainting? ________________________________________________________
___Yes ___No Sleep Walking? ___________________________________________________
___Yes ___No Upset Stomach?___________________________________________________
___Yes ___No Other?___________________________________________________________
Does student have a reaction to: (if “yes” explain)
___Yes ___No Bee Stings? ______________________________________________________
___Yes ___No Penicilin?________________________________________________________
___Yes ___No Other Drugs?_____________________________________________________
___Yes ___No Other?___________________________________________________________
___Yes ___No Has the student had any serious illness or surgery within the past ten years?
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ___Yes ___No Are any drugs ineffective in treatment?_________________________________
___Yes ___No Does the student wear contact lenses?__________________________________
Date of last tetanus shot: ________________________________________________________
Routine Medications needed daily_________________________________________________
______________________________________________________________________________

Student Name:________________________________________________________________
(First) (Last) (M.I)
___Yes ___No Can your student be given over the counter medications such as:
Tylenol, Imodium AD, Tums, etc….for normal ache and pains?
(Parent/Guardian Signature) Date Relationship to student ____________________________________ Does your child have your permission to swim? ___Yes ___No

Source: http://www.troybandboosters.org/yahoo_site_admin/assets/docs/TRIPMEDICALINFORMATION.327112618.pdf