ASHLEY RIDGE HIGH SCHOOL BAND, Summerville, SC 2013-2014 CONSENT FOR MEDICAL TREATMENT TO WHOM IT MAY CONCERN, I, the undersigned parent or guardian of:
Hereby grant authorization to the Band Director or any chaperone of the Ashley Ridge High School Band Boosters, to obtain any emergency medical and/or surgical procedures from a physician or hospital emergency room physician on behalf of the above named minor. Signature____________________________________________________________________Date / / Parent’s Printed Name____________________________________________________________________________
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Student__________________________________________________Phone_________________________________ Address________________________________________________________________________________________ Father’s Name_____________________________________________Work Phone___________________________ Place of Work____________________________________________Title___________________________________ Mother’s Name___________________________________________Work Phone____________________________ Place of Work____________________________________________Title___________________________________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ALTERNATE TO NOTIFY IN CASE OF EMERGENCYNAME_________________________________________________________________________________________ Relationship____________________________________________________Phone___________________________ City_________________________________________________State_______________Zip____________________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FINANCIAL CONSIDERATIONS
For and in consideration of emergency services and goods rendered by or through the attending physician(s), the undersigned hereby guarantees payment in full, immediately upon receipt of the final billing. SIGNATURE___________________________________________________DATE___________________________ 2013-2014 MEDICAL INFORMATION Parents____________________________________________________________Policy #: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PLEASE COMPLETE THE QUESTIONS BELOW. It is imperative that we have medical information in order that we may care for the student in case of emergency. DOES THE STUDENT HAVE ANY CHRONIC HEALTH PROBLEMS?________________________ _______________________________________________________________________________________ IS THE STUDENT ALLERGIC TO ANY MEDICATIONS?___________________________________ ________________________________________________________________________________________ DOES HE / SHE HAVE ALLERGIES?______________________________________________________ ________________________________________________________________________________________ IS HE / SHE CURRENTLY TAKING ANY MEDICATIONS?__________________________________ ________________________________________________________________________________________ WHAT IS THE DATE OF THE STUDENT’S LAST TETANUS SHOT?__________________________ ________________________________________________________________________________________ PLEASE LIST ANY ADDITIONAL PERTINENT INFORMATION_____________________________ ________________________________________________________________________________________
FAMILY PHYSICIAN_____________________________________________________________________________
TELEPHONE ADDRESS__________________________________________________________________________
In case of minor illness, the Ashley Ridge High School Band Director or chaperones of the Band Boosters have my permission to give over the counter drugs such as, but not limited to Tylenol, Maalox, Sudafed, Ibuprofen or Dramamine to my son / daughter.
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