Southaven Band Medical Release Form

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Southaven Band Medical Release Form
Student Name ____________________________________________________________
Parent or Guardian Name(s) _________________________________________________
Street Address ____________________________________________________________
City __________________________ State _____________ Zip Code _______________
Home phone ____________________ (If you do not have a home #, please write “N/A”_
Cell phone __________________ This # belongs to mom ___ dad ___ other __________
Work phone __________________ This # belongs to mom ___ dad ___ other __________
Alternate cell / work numbers: ________________________________________________
EMERGENCY CONTACT NAME: _____________________________________________
EMERGENCY CONTACT PHONE: ____________________________________________
Family Physician: ________________________________ Phone: ___________________
Hospital preference (unless altered by type of injury or condition):
________________________________________________________________________
List any & all illnesses or conditions student has been treated for in the past:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List any and all known allergies (N/A if none known):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List any medications student is currently taking:
________________________________________________________________________
________________________________________________________________________
Insurance Company _____________________________________ Phone _____________________
Address __________________________________________________________________________
Insured Name ______________________________ Social Security # ________________________
Insured ID # _____________________________ Group # _________________________________
I hereby give written permission for my child to be transported via ambulance to the medical facility deemed
necessary for appropriate and immediate medical attention.
Signature of parent/guardian ________________________________ Date __________________
Printed name of signee _______________________________________

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