CG Sound System
Audition Application - Health Form
Student Health Form
Emergency Contact Name
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?
Health Insurance Information
Student's Date of Birth
Health Insurance Company
Health Insurance Policy Number
Policy Holder Name
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