Band Health

If you see this don't fill out this input box.

*Student Name (Last, First)

Nickname on Nametag

*Gender

*Name of Insured (Financially responsible party with authority to make medical decisions)

*Relationship to Student

*Contact Phone

*Provider (if none, state "Not Applicable")

Provider Group #

Provider Policy #

Family Doctor: Name

Family Doctor: City and State

Family Doctor: Telephone Number

*Date of last Tetanus

Preexisting Conditions

Medications

Allergies to food or medications

* Campers requiring emergency treatment will be taken to the University Medical Center emergency room unless otherwise specified. Every effort will be made to contact a parent/legal guardian prior to seeking medical attention; however, the registered nurse will make the decision to proceed based on the safety and welfare of the camper. Parents are responsible for all medical expenses. Please provide the most current insurance information.
* The camp clinic will have a limited supply of over-the-counter medications for aches/pains, upset stomach, allergies, etc. Campers MAY NOT self-administer medications for the following: antidepressants, any controlled substance (including prescription pain medication), and medication for ADD/ADHD. These must be administered through the camp clinic. ALL medications should be properly labeled and in the original container. Please be sure that the student is aware of the proper use of all medications and medical equipment brought to Camp. The Camp is not liable for their loss.

*Administration Choice

My son/daughter will self-sdminister his/her medication while at camp. I understand that these medications will not include any medications for the above named drug categories.

My son/daughter will be taking medication that requires the camp nurse keep and administer the medications. (Please provide detailed instructions.)

Medication administration Instructions, if applicable

*In case of accident or sudden illness/injury to the above-named child and in the event that I cannot be reached by phone, I hereby authorize a representative of Texas Tech All State Choir Camp to seek medical treatment for my child. I hold the Texas Tech All State Choir Camp, its employees, and Texas Tech University harmless from all liability resulting from any accidents or illness to my child. I verify that all information on this form is complete and accurate. I have read and understand all information contained herein.

I agree

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Texas Tech Band and Orchestra Camp

Address

18th and Boston Avenue Box 42033, Lubbock TX 79409-2033
Phone
806.742.2225 | Fax: 806.742.4193
Email
boc@ttu.edu

Band Health

Texas Tech Band and Orchestra Camp

Address

Phone

Email