Student Name (one form per student):_________________________________________ Address:_________________________________________________________________ City:___________________________________ State:___________Zip:___________ Student's S/S #:_________________ DOB:__________ Grade:____ Sex: ____Medical History (mark if a problem):Insurance Co.:___________________________________Accnt #: _____________
Doctor's Name and Phone: _____________________________________________________
_____Diabetes _____Epilepsy _____Asthma ______Other: _____Allergies (please list, i.e. food, medicine, etc.):_________________________________________ _________________________________________________________________________________________________
Mark any of the over-the-counter medications the student may take if needed:
_____Tylenol _____Cortaid Cream _____Cough Syrup/Drops _____Ibuprophen _____Pepto Bismol _____Throat Lozenges _____Sudafed _____Benadryl _____Neosporin Ointment _____Imodium _____Eye Drops _____Bonine (for motion sickness) _____Betadine (to clean cuts) _____Other:
I, (print name of parent/guardian) ____________________________________, give permission
for Mr. David E. Chipman, Director of Bands, or any adult named by Mr. Chipman
to act in my behalf to approve appropriate medical treatment for my son/daughter (print name of student)
________________________________should an emergency medical treatment be necessary
and will make any necessary financial reimbursements. I further state that I am
of lawful age and legally competent to sign this Medical Release; that I understand
that the terms herein are contractual and are not a mere recital; and that I have
signed this document as my own free act. I agree to release and hold harmless
Mr. Chipman or his nominee from any liability for decisions made pursuant to their
authorization. I have fully informed myself of the contents of this Medical Release by reading
it and that the medical and insurance information I give below is accurate.
Signature of Parent/Guardian:______________________________Date:_____/___/_____ Sworn to and subscribed before me this _______ day of ___________ in the year ________
Notary's signature:________________________Commission expires:_______________
Phone: Home__________________ Work __________________ Cell __________________
