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Audition Application - Health Form
Student Health Form
Emergency Contact Name
*
First
Last
Emergency Contact Number
*
Please indicate if any of the following currently apply to your student.
Under the care of a physician for a particular condition
Taking prescription or over-the-counter medication(s)
Allergic to any medications
Had a serious illness, surgery, or hospitalization in the past six months
Do NOT give my student over-the-counter medications (ie. Tylenol, Advil, Imodium D, Tums, Pepto Bismol)
Has Food Allergies
Please describe the particular condition your student is currently under the care of a physician.
*
Please describe which prescription and/or over-the-counter medications your student is taking.
*
Please list what medications your student is allergic to.
*
Please explain the serious illness, surgery, or hospitalization your student had in the last six months.
*
(illness/surgery, date treated)
Which over-the-counter medications do you not want given do your student
*
Please describe which food allergies your student has and the type of reaction they have.
*
Does your student have an EpiPen?
*
Yes
No
Health Insurance Information
Student's Date of Birth
*
Family Physician
*
Hospital Preference
*
Health Insurance Company
*
Health Insurance Policy Number
*
Insurance Address
*
Insurance Phone
*
Policy Holder Name
*
Group Number
