Lloyd C. Bird Skyhawk Band Student Name____________________________________________________________________ Last
Age __________ Date of Birth ________________ Social Security Number ___________________
Address _________________________________________________________________________ Street & Number
Parent/Guardian Names & Address ________________________________________________________________________________ Mother’s Name
_______________________________________________________________________________________________ Mother’s Home Phone
________________________________________________________________________________ Father’s Name
_______________________________________________________________________________________________ Father’s Home Phone
Emergency Contact (Other than parent or guardian) ________________________________________________________________________________ Name
_______________________________________________________________________________________________ Home Phone
Student’s Doctor______________________________________________________________________________
Medical History Does student have a Medical Treatment Plan on file with Chesterfield County Schools? ___________ If yes, a copy must be attached to this form. Check if your student has any of the following. Chronic Ear Infections _______
Other (specify) ______________________________________________________
Describe their conditions, reactions and treatments in space below. ________________________________________________________________________________ _______________________________________________________________________________________________ ________________________________________________________________________________ Surgeries, Hospitalizations or Other Serious Injuries/ Conditions Not Listed Above ________________________________________________________________________________ Date Last Tetanus Shot _______________ Lloyd C. Bird Skyhawk Band Student Name ___________________________________________________________________ Last Allergies (Circle type) Reaction Treatment
Drug, Food, Insect sting _____________________ ____________________ ____________________________
Drug, Food, Insect sting _____________________ ____________________ ____________________________
Drug, Food, Insect sting _____________________ ____________________ ____________________________ Does student carry an “Epi Pen” or inhaler? _____________________________________________ Medications Taken _______________________________________________________________________________________ Name _______________________________________________________________________________________ Name _______________________________________________________________________________________ Name _______________________________________________________________________________________ Name
ALL MEDICATION MUST BE LEFT WITH THE DESIGNATED CHAPERONE DURING TRIPS. CHAPERONE WILL ADMINISTER MEDICATIONS LISTED ABOVE WHEN NEEDED.
Check “Yes” or “No” to indicate if the student may receive over-the-counter drugs from a band parent:
Over the Counter Drug Common uses HEALTH INSURANCE __________________________________________________________________________________ Company YOU ARE REQUIRED TO ATTACH A FRONT & BACK COPY OF YOUR HEALTH INSURANCE CARD TO THIS FORM
I give permission for ______________________________(son/daughter’s name) to travel with the Lloyd C. Bird Skyhawk Band on all of the dates on the fall marching band calendar. I give my consent to have my son or daughter treated should a medical emergency arise. I understand every effort will be made to contact me should an emergency arise. Parent or Guardian Signature ________________________________ Date _______________________
Fluoroscopy Questions the Central Scheduler May ask when scheduling an exam: IS THE PHYSICIAN ORDERING ANY ORAL SEDATION FOR THIS EXAM? IS THIS BEING SCHEDULED BY SPEECH PATHOLOGIST? IF NOT PLEASE REFER TO SPEECH PATHOLOGIST. IF YES PLEASE ENTER NAME OF SPEECH PATHOLOGIST SCHEDULING. PLEASE HAVE THE PATIENT BRING A CURRENT LIST OF MEDICATIONS THEY ARE TAKING TO INCLUDE NON-PRESCRIP
Articles Breast cancer and breastfeeding: collaborative reanalysis ofindividual data from 47 epidemiological studies in 30 countries,including 50 302 women with breast cancer and 96 973 womenwithout the disease Collaborative Group on Hormonal Factors in Breast Cancer *IntroductionAlthough childbearing is known to protect against breastBackground Although childbearing is known to protect agai