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Medical form sept 27 2012

MPSMA—MEDICAL RELEASE/INFORMATION FORM TODAY’S DATE:______________________________

Participant’s Name: _________________________________________ Date of Birth:____________________________

Street Address: _____________________________________________________________________________________
City:_________________________________________ State:______________ Zip Code_________________________
Emergency Contact #1_________________________________________________________________________

Relationship
Phone (please designate if cell, work or home)

Emergency Contact #2_______________________________________________________________________________

Relationship
Phone (please designate if cell, work or home)
Pertinent Past Medical History (including past hospitalizations & surgeries). (Use reverse side if needed).:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

Currently under the care of a physician for:
_______________________________________________________________________________________________________________
I give my permission for my son/daughter to take or be given the following over the counter medication (OTC): (Please circle all that apply)
Advil/Motrin
Pepto Bismol
Imodium A-D
Benadryl
Cough Drops

Other over the counter medication and/or Herbal Medication: Please List:________________________________________________
Food & Drug Allergies (if more space is needed, please use reverse side):

__________________________________________________ ______________________________________________________ __________________________________________________ ______________________________________________________ Medications my son/daughter is currently taking. Include all over the counter & Prescription medication taken regularly (use reverse side if needed).
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
My son/daughter has my permission to carry his/her own Inhalers or Epi-Pen (please check if you approve)
PRIMARY INSURANCE: Policy #: ________________ Group #:_________________________ ID#: ________________
Name & Address of Insurance Company: ___________________________________________________________________ dental insurer, please put
Phone # :___________________________________Policy Holder (Employer):_____________________________________ and include copies of the
Employee’s Name:____________________________Relationship to student: ______________________________________
In the event of an emergency or non-emergency requiring medical treatment, I _________________________________________________, hereby grant permission for any and all medical and/or dental attention to be administered to my child,________________________________ in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. Parent/Guardian’s Name (SIGNATURE): ______________________________________________________ Date: ____________________ Parent/Guardian’s Name (PRINT): _____________________________________________________________________________________ Phone numbers: Cell_____________________________; Home;_____________________________; Work: __________________________

Source: http://mpsmusic.org/index_files/MedicalForm2012.pdf

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