STUDENT MEDICAL INFORMATION Send to FESTIVAL HOST DIRECTOR

NAME _______________________________________________________________

SCHOOL _____________________________________________________________

BIRTHDATE________________ SOCIAL SECURITY NUMBER________________________

FATHER’S FULL NAME______________________WORKPHONE__________HOURS_______

(STEP OR GUARDIAN)

MOTHER’S FULL NAME______________________WORKPHONE__________HOURS______

IF THE PARENTS (GUARDIANS) LISTED ABOVE CAN NOT BE CONTACTED, LIST TWO CONTACTS BELOW. NAME____________________________PHONE_________RELATIONSHIP_________

NAME____________________________PHONE_________RELATIONSHIP_________

PLEASE LIST ANY MEDICATIONS THE STUDENT IS CURRENTLY TAKING. INCLUDE NAME AND PHONE # OF PRESCRIBING PHYSICIAN)______________________________________________________________

_________________________________________________________________________________

PLEASE LIST ANY CONDITIONS YOUR CHILD HAS, INCLUDING ALLERGIES.________________________________________________________________________________________________________________________________

DATE OF LAST TETNUS SHOT__________PREFERRED DOCTOR/HOSPITAL______________

NAME OF HEALTH INSURANCE_______________________________________________

ADDRESS__________________________________________ PHONE_____________

NAME OF GUARANTOR____________________ AGREEMENT #____________________

NAME OF EMPLOYER (IF GROUP INSURANCE)_____________________________________

EMPLOYER’S ADDRESS__________________________________PHONE____________

IF A STUDENT IS NOT COVERED BY A FAMILY OR OTHER TYPE OF MEDICAL INSURANCE PLAN, THE PARENT/GUARDIAN(S) WILL BE RESPONSIBLE FOR ALL MEDICAL EXPENSES. PMEA DOES NOT CARRY MEDICAL INSURANCE FOR FESTIVAL PARTICIPANTS.  IF CONTACTS LISTED ABOVE CAN NOT BE CONTACTED, WHAT DO YOU WISH THE SCHOOL OR FESTIVAL HOST TO DO IN CASE IF AN ACCIDENT OR ILLNESS?____________________________________
________________________________________________________________________

IF EMERGENCY TREATMENT IS REQUIRED, MAY THE SCHOOL AUTHORITIES, FESTIVAL HOST, OR DESIGNEE USE THEIR OWN JUDGMENT IN SENDING THE CHILD TO A DOCTOR OR HOSPITAL MOST EASILY ACCESSIBLE BEFORE THE PARENTS/GUARDIANS CAN BE REACHED? YES NO

IT IS UNDERSTOOD THAT, IN THE FINAL DISPOSITION OF AN EMERGENCY CASE, THE JUDGMENT OF THE SCHOOL AUTHORITIES WILL PREVAIL. THE RECOMMENDATION OF THE PARENT/GUARDIAN, AS INDICATED ABOVE, WILL BE RESPECTED AS FAR AS POSSIBLE. IF AT ANY TIME THE ABOVE INFORMATION CHANGES, THE PARENTS WILL NOTIFY THE CHILD’S MUSIC TEACHER AND/OR FESTIVAL HOST IN WRITING.

ALL BLANKS MUST BE COMPLETED - PMEA IS NOT RESPONSIBLE FOR INCORRECT OR MISSING INFORMATION

PARENT (GUARDIAN) SIGNATURE____________________________________________

DATE________________________________________________________________