School Band Pre-Participation Medical Screening Form

Student Information

Full Name

Date of Birth

Grade

Instrument(s)

Parent/Guardian Contact

Parent/Guardian Name

Phone Number

Email

Medical History

Allergies

Yes No

Asthma

Yes No

Diabetes

Yes No

Other Medical Conditions

Current Medications

Emergency Contact

Name

Relationship

Phone Number

Physician Information

Physician Name

Phone Number

Parent/Guardian Signature

Signature

Date