Medical Form & Release
The following information is for use only in the case of an emergency. The information you provide will aid emergency and other healthcare professionals to best help your child in a moment of need. Please complete each section to the best of your ability. Any changes may be made at the parent or guardian’s discretion as the change arises.
STUDENT: ______DOB: ______
PARENT/GUARDIAN #1 NAME: ______RELATIONSHIP: ______
ADDRESS:______
Number/Street City State Zip
PHONE: ______PHONE #2: ______
PARENT/GUARDIAN #1 NAME:______RELATIONSHIP: ______
ADDRESS:______
Number/Street City State Zip
PHONE: ______PHONE #2: ______
EMERGENCY CONTACT: #1 NAME: ______RELATIONSHIP: ______
(if parent cannot be reached)
ADDRESS:______
Number/Street City State Zip
PHONE: ______PHONE #2: ______
Medical Info/History
Insurance Provider: ______Policy #______Group#______
Physician Name:______Phone #: ______
Student Health Conditions / Circle One / DetailsASTHMA / YES NO / Inhaler??
ALLERGIES / YES NO / List:
BLOOD DISORDERS / YES NO
DIABETES / YES NO
HEART ISSUES / YES NO
SIEZURES / YES NO
MIGRAINES / YES NO
OTHER / YES NO / List:
Medications: List all Current ROUTINE Medications & Dosage (MUST be sent in Original Container)
Over the Counter (OTC) Medications:
The Band Parent Organization will travel equipped with basic first aid capabilities. By circling Yes or No below, you are designating permission for the listed OTC medication (or generic equivalent) to be given to your child, upon reasonable complaint and/or minor injury (scrape, minor cut, etc.), by an Nease Band Chaperone or Staff Member in accordance with the Manufacturer’s directions:
Medications / Circle One / Medications / Circle OneIbuprofin (Advil, Motrin) / YES NO / Benadryl (topical) / YES NO
Acetaminophen (Tylenol) / YES NO / Intestinal Meds (pepto, tums, etc) / YES NO
Benadryl (oral) / YES NO / Topical Antibiotic (Neosporin, etc) / YES NO
I hereby give my permission and consent for my student to participate in all band activities, including practices, home and away games, competitions, trips and other music-related events throughout the school year. I further give my permission and consent for my student to be supervised by the band director and any designated chaperones at such events. I also authorize the band director and any designated chaperones to obtain, through any licensed medical personnel/physician of their own choosing, any medical care that they deem reasonably necessary should my child be injured or become seriously ill during any and all functions. I hereby grant permission to licensed hospital and/or health center staff members to administer immediate medical treatment as deemed necessary. Further, I understand that I am responsible for payment of expenses incurred relating to my child’s medical treatment. I agree to keep all medical information previously provided about my student up to date.
I acknowledge and understand the risks involved in these events and grant permission for my child to attend and assume those risks. I further agree to release the St. John’s County School Board, its officers, agents, and employees, exercising reasonable care within their scope of employment from liability growing out of personal injuries and property damage resulting or occurring during the aforementioned activity, or in transit to and/or from the activity. I agree to hold harmless the band director, Nease Band Boosters, Inc., and any designated chaperones.
Parent/Guardian Signature ______Date______
Student Signature______Date______