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Microsoft word - medical form

GRANT BANDS
MEDICAL RELEASE and
PERMISSION FORM
Student__________________________ Gender M F (circle) Grade_______ Address________________________________________ T-shirt size____
City________________________ State_____ Zip____ Date of Birth__________
EMERGENCY PHONE NUMBERS
(Please print legibly)
Contact
MEDICAL INSURANCE INFORMATION (please keep updated)
Insurance Company ____________________________________________________
Policy # __________________________ Group # ___________________________ ID #_____________________________OTHER#____________________________
PERMISSION
I give _______________________ permission to participate in all activities of the Grant High
School Band as approved by the school administration and the Grant Public Schools Board of
Education during the 2012-2013 school year. I give the Band Director and/or authorized chaperones
and/or certified medical personnel authority to seek and/or render medical aid for my child in the
event of an illness or injury. I understand that at least one person listed above is to be contacted
should the listed child become ill or injured.
Parent / Guardian ______________________________________ Date ______________________
The medical information provided on the back of this form is confidential. It will only be
viewed by volunteers providing first aid, paramedics or emergency physician.
EMERGENCY MEDICAL INFORMATION
Student name____________________________ (Please print legibly) ALLERGIES (Fill in or write NONE) ______________________________________________________________________________ ______________________________________________________________________________ MEDICATION STUDENT IS NOW TAKING (Prescription, Non-prescription, or NONE – include dosage information) ______________________________________________________________________________ ______________________________________________________________________________ CHRONIC HEALTH PROBLEMS / CONCERNS (Fill in or write NONE) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SPECIAL NEEDS (Fill in diabetic supplies, inhaler, etc., or NONE) ______________________________________________________________________________ ______________________________________________________________________________ DIETARY RESTRICTIONS (Fill in or write NONE) ______________________________________________________________________________ ______________________________________________________________________________

While with the band, my child may take the following common over-the-counter medicines
according to recommended dosages, if he/she requests:
(Check approved medicines)
___ Acetaminophen (Tylenol)
___ Other ________________________________ ___ My child should not take any of these medications.
Parent / Guardian _____________________________________ Date ___________________

Source: http://www.grantps.net/uploads/abuikema/band%20camp/Medical%20Form.pdf

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