Microsoft word - medrelform.doc

Permission for Medical Treatment
This notarized form must be on file
Full Name of Band Member: ______________________________________________________ Birth Date: ______________________________________ To Whom It May Concern: I, the undersigned, being the parent, legal guardian, or legal next-of-kin of the
band member whose name appears on this form, do hereby authorize any necessary medical treatment for this
person while participating in the activities of the Blacksburg High School Band. I also guarantee payment of
all charges incurred during the treatment (ambulance, physician, hospital, X-ray, lab, drugs, etc.).
Furthermore, I hereby give my permission for the band member named above to attend and participate in all
functions and trips taken by Blacksburg High School Band.
Medical Information: Please respond to each question. Where there are no problems, write “none.”
1. Allergies to foods, medication, etc. _____________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ 2. Is student now under medical care? Yes  No  If yes, describe the nature of illness and treatment. ___________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 3. Does participant carry medication on person? Yes  No  Name of medication. __________________________________________________________________ Purpose for using medication ____________________________________________________________ ___________________________________________________________________________________ 4. Special medical problems (not mentioned above). _________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 5. Date of last tetanus shot. _____________________________________________________________ 6. Physician of student. ________________________________________________________________ Physician’s phone ____________________________________________________________________ 7. Has permission to take aspirin (or related painkiller)? 8. Medical Insurance Provider ___________________________________________________________ Policy No. ___________________________________ Group No. ____________________________ Name that appears on the insurance card ___________________________________________________
I certify that to the best of my knowledge the above information is correct. In my absence, I do
hereby authorize permission for medical/emergency treatment for the person listed on this

Parent Or Legal Guardian:

Signature ____________________________________________________________________

******** SIGNATURE MUST BE NOTARIZED ******** Date _______________________________ Mother’s Name ________________________________________________________________ Address ______________________________________________________________________ Home Phone _________________________ Work Phone _____________________________ Cell/Mobile/Alternative Phone ____________________________ Father’s Name _________________________________________________________________ Address ______________________________________________________________________ Home Phone _________________________ Work Phone _____________________________ Cell/Mobile/Alternative Phone ____________________________ Emergency contact if parent or guardian is not available (name and phone number) _____________________________________________________________________________ _____________________________________________________________________________


Gme21407 250.252

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