Kingsway
Regional School District
Marching
Band
Emergency
& Medical Information Sheet
Student ___________________________________________________________________________
Street Address _____________________________________________________________________
City ________________________________ Zip Code _____________
Home Phone ( )_______________________
Student Cell Phone ( )__________________
Age _____ Grade ______ Date of Birth _________________
Emergency Contact Info:
1st Contact Person: __________________________ Daytime Phone: _______________
Relation to Student: ________________________ Cell Phone: ___________________
Work Phone: __________________
2nd Contact Person: _________________________ Daytime Phone: ________________
Relation to Student: ________________________ Cell Phone: ___________________
Work Phone: __________________
Family Physician Name and Phone Number: ___________________________________
Hospital Preference:_____________________________________
Please list any Medical Alerts such as allergies or medications: _____________________
________________________________________________________________________
________________________________________________________________________
Medical Insurance Information:
Company: _________________________________________
ID#: _________________________
Group # (if applicable): ______________________