Formreviewed by the Pa Dept of Health/Division of School Health, 2014

STUDENTMEDICALINFORMATIONFORM

PENNSYLVANIAMUSICEDUCATORSASSOCIATION

FORMREVIEWED BY THE PA DEPT OF HEALTH/DIVISION OF SCHOOL HEALTH, 2014

Pleasecircleinwhichensemblestudentwillparticipate: Band,WindEnsemble,Chorus,Orchestra,Jazz,VocalJazz

StudentName SexAgeDateofbirth

Date______

Grade

HomeAddress:

Street

City,State,ZipCode

AreaCode/Phonenumber

Director’sName

School

Father’sFullNameWorkPhoneHours

Mother’sFullNameWorkPhoneHours

Stepparent/Guardian’sFullName WorkPhoneHours

Isthestudentcurrentlyundermedicaltreatment?YESNO

Ifyes,givethenatureofthetreatmentandthedoctor’snameandphonenumber:

Isthestudentcurrentlytakinganymedications? YESNO

Ifyes,will the student require medications during the festival? YES NO

If yes, a separate medication administration form will need to be completed for each medication, including parent/guardian permission and licensed prescriber signature (see attached).

Listanyspecial health needsofwhichtheschoolnurseormedicalpersonnelshouldbemadeaware(allergies,diabetes,heartcondition,foodallergies,etc.)

Is your child allergic? YESNO If yes, please list all allergies:______

______

If yes, have any of these allergies caused an anaphylactic reaction? YESNO

Dateoflasttetanusshot:

Nameofhealthinsurance:

AddressPhone

Nameof GuarantorAgreement#

NameofEmployer(ifgroupinsurance)

AddressPhoneGroup#

PENNSYLVANIAMUSICEDUCATORSASSOCIATION FIRSTAID/EMERGENCYTREATMENTAUTHORIZATION

Iftheschoolorfestivalhostcannotcontacteitherparent/guardian,pleaselisttworelativesorfriendswhowould havetheauthoritytoadviseusregardingyourchild:

NameRelationshiptoChild Address Phone Name RelationshiptoChild Address Phone

IfEMERGENCYTREATMENTisrequired,schoolauthorities,festivalhost,ordesigneewill usetheirown judgmentinsendingthechildtoahospitalordoctormosteasilyaccessiblebeforetheparent/guardiancanbereached.

Nameof preferredhospital

Name of preferreddoctor

If your child needs to be given medication during school hours, aseparate Medication Administration Record form for each medication to be administered must be completed.

Itisunderstoodthatinthefinaldispositionofanemergencycase,thejudgmentoftheschoolauthoritieswill prevail.Therecommendationoftheparent/guardian,asindicatedabove,willberespectedasfaraspossible.

If atanytimetheaboveinformationmustbechanged,Iwillnotifymychild’smusicdirector/orfestivalhost

directorinwriting.Itisunderstoodandagreedthatthechildandhis/herparent/guardianshallholdharmlessPennsylvaniaMusicEducatorsAssociation,thehostschooldistrict,andanyregisterednurseemployedbyPMEA,fromanyandalllawsuits,claims,demands,expensesorcostsarisingoutoftheadministrationoforfailuretoadmin- isterfirstaidoremergencytreatmenttothechildwhilein attendanceataPMEA-sponsoredmusicalprogramor festival,includingpracticesessions.

SignatureofparentorguardianDate

Thismedicalform will beprovidedtothehostfamilyand/ornurseoncall.

PARENT/GUARDIANSIGNATURESTUDENTSIGNATURE

RevisedFebruary 2014