Burgettstown Area High School Bands
2011-2012
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Medical Information/Liability Release Form
***Please attach a current photo of student***
I. Student Information
Name: ______Age: ______
Address: ______
City, State, Zip: ______
Parent’s/Legal Guardian’s Name(s): ______
Home Phone Number(s): ______
Work Phone Number(s): ______
Emergency Contact Person: ______
Phone Number of Contact Person: ______
II. Medical Information
A. Date of Last Tetanus Shot: ______
B. Please check the following medical conditions that apply and explain any precautions, treatments, and medications with dosages necessary for your child’s health care.
Asthma ______
Diabetes ______
Surgeries ______
Allergies ______
Please list all allergies and detail reactions and treatments: ______
______
Other medical conditions (please explain): ______
______
III. Physician/Insurance Information
Family Doctor: ______
Phone Number: ______
Insurance Provider: ______
Phone Number: ______
Does your insurance require advance notice? ______
Please list any other information relevant to procedures dealing with your primary care physician and insurance provider. ______
______
______
The Burgettstown High School Band Staff and Adult Chaperones are able to provide only basic First Aid and treatment of minor illnesses or injuries. All other treatments will be obtained from the provided medical personnel on site, or by transporting your child to the nearest medical facility. The main concern is to keep your child safe. Please discuss with your child any current medical problems that he/she may have, thus enabling them to provide responsible and accurate information when required. If your child is taking prescribed or over-the-counter medication(s), this must be the responsibility of your child. All medications must be in their original container with your child’s name and directions for use. If there are special circumstances regarding medications, a personal discussion with the band director must take place.
I/We hereby release the Burgettstown High School Band Staff and Adult Chaperones from medical and/or legal liability from any unforeseen circumstances resulting during the supervision of my/our child.
PARENT/LEGAL GUARDIAN SIGNATURE: ______
DATE: ______
In the event of an accident or illness, I, ______, Parent/Legal Guardian of ______, hereby grant my permission for my child to be transported to the nearest hospital or bona fide health facility and for medical treatment and/or medicines.
PARENT/LEGAL GUARDIAN SIGNATURE: ______
DATE: ______