MHS Band Medical Form

Please type or print.

Circle: M         F         Social Security number:_____________________Age___________

Last Name:_________________First Name___________________Middle Name____________

Address:_______________________________________Phone # (         )__________________

City:_________________________________State_________Zip Code____________________

Notify in Case of an emergency:

Name:_______________________________  Name__________________________________

Relationship:__________________________  Relationship:____________________________

Address:_____________________________   Address________________________________

____________________________________    ______________________________________

Telephone Number (       )_______________    Telephone Number(       )__________________

If no Answer:__________________________    If no Answer___________________________

List any history of serious illnesses or injuries with date of occurrence:____________________

____________________________________________________________________________

List any surgery and date of occurrence:____________________________________________

List any allergies to medicine:____________________________________________________

When did you last have your tetanus toxoid?_________Do you wear contact lenses?_________

List any chronic illnesses and medications taken:_____________________________________

____________________________________________________________________________

Doctor’s Name_____________________________Telephone Number: (      )______________

Address:_____________________________________________________________________

Parents of Minors:   I hereby agree that medical personnel may administer first aid and necessary treatment in case of emergency and /or refer patient to a local clinic or hospital for treatment.

Signature:________________________________________Date:________________________

Health insurance by which Participant is covered:______________________________________

Policy Number____________________________

I give permission for my child to take (circle one or both) ibuprofen or tylenol.  :      _____ (initial)