Microsoft word - medical release 2011-2012.doc

MEMBERSHIP TRACKER
This page must be filled out, signed by parents and students, and returned to your section leader
before the school year begins.

The material below will serve as information needed in case of an emergency. This information letter
will also serve as a permission form for your son/daughter to participate in band trips or functions with
the Mary G. Montgomery High School Band during the 2011-2012 school year.
I give my permission for my child to ride to and from all band functions with the band. I understand that my child MUST participate in each event. I have received a calendar of these events. If I (the parent/guardian) will be picking my child up from one of these events I will submit that in writing before the event. Student Name ____________________________________ (print) _____________________________________ (sign) Parent/Guardian ___________________________________ (print) ___________________________________ (sign) Date
Med. Given
Date
Med. Given
ALLERGIES:____________________
Section:_________________________
MGM VIKING BAND
STUDENT MEDICAL INFORMATION

Student’s Legal Name: _________________________ Preferred Name:____________________________
Student’s Social Security Number: _________________________ Birthday: _______________________
Parent/Guardian Name: __________________________________________________________________
Address: ______________________________________________________________________________
City: ____________________________________ State: ________________ Zip: _________________
Phone: Home ______________________ Work: mom ______________ Cell mom _____________
parent email_______________________________ student email _________________________________ Emergency contact (other than parents) Contact 1 Name: ___________________________________ Phone: ____________________________ Contact 2 Name: ___________________________________ Phone: ____________________________ Serious Illnesses or Operations: ____________________________________________________________ Unusual Health Conditions: Yes _____ No _____ If yes, explain _______________________________ ______________________________________________________________________________________ Regular Medications Taken: ______________________________________________________________ Doctor: _____________________________________________ Phone: __________________________ PERMISSION FOR MEDICAL TREATMENT

If emergency treatment is required and parents cannot be reached, what does the parent want the school to do? 1.
Contact closest medical facility? Yes ____ No ____
2. Contact a physician from local referral agency? Yes ____ No _____
3. Take child to nearest hospital ? Yes ___ No _____
4. Other suggestions ___________________________________________________
I give my child permission to receive: ____ Tylenol OR _____ Ibuprofen for pain
____ Dramamine for nausea
____ Hydrocortisone cream for itching
____ Benadryl for allergic reactions
____ Imodium for diarrhea

INSURANCE INFORMATION
Policy Holder: ________________________________ Ins. Company Name________________________
Policy Holder’s Birthday ________________________SS# _____________________________________
Member Number ______________________________ Policy Number: ___________________________
Insurance Customer Service Number: _______________________________________________________
Parent/Guardian Signature: ______________________________________________

Source: http://www.mgmband.com/files/Medical_release_2011-2012.pdf