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*03 supplemental info-sect 03

NEW HAMPSHIRE MUSIC EDUCATORS’ ASSOCIATION
A Division of MENC – National Association for Music Education – MEDICAL FORM –
PLEASE PRINT
Last Name: ___________________________ First Name:_______________________________ DOB: _________ Age: ____ Grd: ____ Sex: _____ Performing Group: __________________ Custodial Parent/Guardian:________________________________ Home Tel: _______________ Mother’s cell phone: _____________________ Mother’s work phone:______________________ Father’s cell phone: ______________________ Father’s work phone: ______________________ Home Address: __________________________ Mailing Address:_________________________ School _______________________________ Director’s Name ___________________________ OTHER THAN ABOVE, IN CASE OF EMERGENCY, PLEASE NOTIFY
Name:________________________________ Relationship:_____________________________ Home Address:_________________________ Tel:______________ Cell phone:_____________ Business Address:_______________________ Tel:______________ Cell phone:_____________ Family Physician:_______________________________________ Tel: _____________________ HEALTH HISTORY
Heart Trouble (explain):________________________________________________________________Blackouts/Convulsions (explain):________________________________________________________Diabetes (Detail of treatment & control): _____________________________________________________________________________________________________________________________________Asthma or Bronchitis:_________________________________________________________________Uses inhaler:______________________________ Patient has inhaler:__________________________Date of last tetanus immunization:________________________________________________________ ALLERGIES
Bee Sting: ________ Penicillin: ________ Food: ________ Environmental:_____________Type of Reaction and Severity: _________________________________________________________Other (explain):_________________________________________________________________________________________________________________________________________________________Are there any conditions/illnesses for which this student is currently receiving treatment or medication?Yes: _____ No: _____ Explain: ________________________________________________________Please describe and list medications:______________________________________________________Does the student have the medication in his/her possession? Yes: ______ No: ______ Please see reverse side for a list of over-the-counter medications. IN CASE OF A MEDICAL EMERGENCY, I HEREBY AUTHORIZE ANY LICENSED
PHYSICIAN, HOSPITAL, CLINIC OR OTHER MEDICAL FACILITY TO HOSPITALIZE
AND SECURE PROPER TREATMENT FOR MY CHILD NAMED ABOVE.
Health Insurance Company: _____________________________ Policy No: __________________ NO STUDENT WILL BE ALLOWED TO PARTICIPATE WITHOUT THIS FORM PROPERLY COMPLETED AND RETURNED.
Permission For Dispensing of Over-the-Counter Medications
Please initial beside the medications that may be given to your child
by the NHMEA Nurse on site:
_______ Neosporin ointment/triple antibiotic ointment (for cuts) _______ Benadryl (for allergic reactions) _______ Hydrocortisone cream (for rashes) _______ Mylanta tablets (for upset stomach) _______ I do not want my child to receive ANY over the
counter medications during the Festival.
NHMEA Official Medical FormApproved: 3/9/08

Source: http://nhmea.org/assets/files/nhmea-med-form.pdf

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