Eastern Michigan University Marching Band
Student Insurance Form
Please completely fill out this form and submit with a copy of your insurance card at Pre-Camp or Band Camp registration.
These can also be mailed to: Eastern Michigan University
University Bands
N-101 Alexander
Ypsilanti, MI 48197
Please attach a copy (front and back) of your insurance card.
Fresh / Soph
Student’s Name: __________________________________ Student ID:___________________ Year: Jr / Sr / Grad St.
Campus Address:____________________________________________________ Phone: (___)___________________
Home Address:______________________________________________________ Phone: (___)___________________
City
State
ZIP
Date of Birth: ____________________
Father/Guardian: ________________________________________________ Phone: (___)_______________________
Home Address:____________________________________________________________________________________
City
State
ZIP
Mother/Guardian: ____________________________________________ Phone: (___)___________________________
Home Address:____________________________________________________________________________________
City
State
ZIP
Medical Insurance Company: _________________________________________________________________________
Claims Address: ___________________________________________________________________________________
City
State
ZIP
Policy/Group Number:_______________________________________________ Phone: (___)_____________________
!
I do not have medical insurance
Emergency Contact: ______________________________________________ Phone: (___)_______________________
Relationship:______________________________
In the event of an emergency or for medical treatment, I hereby authorize the Eastern Michigan University Bands to obtain
medical services for myself; I fully understand and agree that I (or my parent/guardian) shall assume full responsibility for
paying any and all medical bills which result from the medical treatment and/or emergency medical treatment.
(A photocopy of this authorization shall be deemed effective and valid as the original.)
____________________________________________________________________________________
Signature of Student
Date
____________________________________________________________________________________
Signature of Parent/Guardian if Student is under 18
Date
Eastern Michigan University Marching Band
Student Insurance Form
E Number: _______________________ Date: _______________
Name: ____________________________________ Gender: _______ Age: _______ Date of Birth: ______________
Personal Physician: ___________________________________________________ Phone: (___)_________________
Physician’s Address:________________________________________________________________________________
City
State
Please explain “yes” answers in the space provided below:
ZIP
Yes No
1. Have you ever been hospitalized?...............................................................................................................................................
Have you ever had surgery..........................................................................................................................................................
2. Are you presently taking any medications or pills?......................................................................................................................
3. Do you have any allergies (medicine, bees, foods, etc.)? ...........................................................................................................
4. Have you ever passed out during or after exercise? ...................................................................................................................
Have you ever had chest pain during or after exercise? .............................................................................................................
Do you tire more quickly than your friends during exercise? .......................................................................................................
Have you ever had high blood pressure? ....................................................................................................................................
Have you ever been told that you have a heart murmur?............................................................................................................
Have you ever had racing of your heart or skipped heartbeat? ...................................................................................................
Has anyone in your family died of heart problems or a sudden death before age 50? ...............................................................
5. Do you have any skin problems (itching, rashes, acne)? ............................................................................................................
6. Have you ever had a head injury? ...............................................................................................................................................
Have you ever been knocked out or unconscious? .....................................................................................................................
Have you ever had a seizure? .....................................................................................................................................................
Have you ever had a stinger, burner or pinched nerve?..............................................................................................................
7. Have you ever had heat or muscle cramps? ...............................................................................................................................
8. Do you have trouble breathing or do you cough during or after activity?.....................................................................................
9. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)? .................................................
10. Have you had any problems with your eyes or vision?................................................................................................................
Do you wear glasses or contacts or protective eye wear? ..........................................................................................................
11. Have you had any problems with your ears or hearing? .............................................................................................................
12. Have you ever sprained/strained, dislocated, fractured, or had repeated swelling or other injuries of any bones or joints?.......
13. Have you had any other medical problems (infectious mononucleosis, diabetes, inflammatory bowel disease, etc.)? ..............
14. Have you had a medical problem or injury since your last evaluation? .......................................................................................
15. Have you ever missed a rehearsal/performance due to an injury/illness? ..................................................................................
16. When was your last tetanus shot? ___________________
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Please explain any “yes” answers below (indicate which corresponding question):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Dietary Restrictions (Please Circle)
VEGETARIAN
GLUTEN-FREE
NON-DAIRY OTHER___________________
NOTE: Completion of this Medical History Form does not substitute in any way for a comprehensive medical examination.
I hereby state that, to the best of my knowledge, my answers to the above questions are correct:
__________________________________________________________________________________________
Signature of Student
Date
__________________________________________________________________________________________
Signature of Parent/Guardian if Student is under 18
Date