STUDENT INFORMATION

Name: ___________________________________________________________________

Last                        Middle                   First

Instrument:________________________________________________________________

Type                       Make                      Model                    Serial Number

E-mail Address:____________________________________________________________

Used to relay information about the LHS Band ONLY

T-Shirt Size ____ Small ____ Medium ____ Large ____ X-Large ____ XX-Large

PARENT/GUARDIAN INFORMATION

Father/Guardian:___________________________________________________________

Last                        Middle                   First

Mother/Guardian: __________________________________________________________

Last                        Middle                   First

E-mail Address:____________________________________________________________

MEDICAL INFORMATION

FORM C                                                                                                                                                  FILE: IFCB

FILE COPY

                            HARRISON COUNTY BOARD OF EDUCATION

                                   EMERGENCY MEDICAL TREATMENT

APPLICANT'S NAME:______________________________________________________

Last                        Middle                   First

ADDRESS:________________________________________________________________

TELEPHONE NUMBERS (____)________________(____)____________________(____)______________________

(HOME)                                 (Father-Bus.)                                (Mother-Bus.)

Is he/she allergic to any medicine or drug? ____ If so, please explain:

__________________________________________________________________________

Has he/she had tetanus shots? _________ When: ______________ Blood Type:__________

Family Physician: ________________________________ Religion: ___________________

Instructions for emergency medical treatment: _____________________________________

___________________________________________________________________________

___________________________________________________________________________

Medicines being taken: ________________________________________________________

Insurance Company:___________________________________I.D.#___________________

FOR THE PARENT OR GUARDIAN:

I hereby grant permission for the above applicant to participate in extra-curricular activity. In the event of accident or medical illness, permission is granted for any such medical and/or surgical treatment as may be necessary. Every effort will be made to notify me before any major treatment is undertaken.

_________________________________

Signature of Parent or Guardian