Ghs Band Medical Release Form printable pdf download

GHS Band Medical Release Form

2015-16

All rules and regulations and punishments, as approved by the York County School Board, and listed in the GHS Student

Handbook are applicable during the all GHS Band travel. Your signature below indicates that you are aware of the rules and that

you agree that the attending student will follow them.

Student’s Name (Please Print) ____________________________________________________________________________

Insurance coverage is provided by ___________________________________________________________________________

Policy Number ________________________________and will provide payment for medical treatment for my son/daughter

while traveling or performing with the band. I also agree to pay any additional medical or transportation expenses that arise from

any emergency, whether medical or behavioral.

Parent Signature ____________________________________________________Date _______________________________

Printed Parent Name ____________________________________________________________________________________

Student’s Date of Birth__________________Student’s Cell #__________________Grade________Instrument______________

Family Physician________________________________________Phone #_________________________________________

PLEASE NOTE ANY MEDICAL PROBLEMS AND LIST ALL MEDICATIONS THAT MUST ACCOMPANY YOUR STUDENT. IF THE

STUDENT HAS FOOD OR DRUG ALLERGIES, PLEASE NOTE. IF NONE, PLEASE STATE NONE.

Medical Conditions (Acute and/or Chronic):

_____________________________________________________________________________________________________________________

Medications/Dosages:

_____________________________________________________________________________________________________________________

Drug/Food Allergies:

_____________________________________________________________________________________________________________________

PLEASE SIGN YOUR INITIALS BESIDE ANY MEDICATIONS YOUR CHILD MAY REQUEST/RECEIVE FROM A CHAPERONE FOR

MINOR DISCOMFORTS:

Benadryl_______

Advil________

Tylenol________

Sudafed_________

Claritin________

Dramamine________

Emetrol________

Immodium_____

Pepto Bismol_______ Tums_______

Cough Drops_____

Benadryl Cream_____Neosporin Ointment_______

ANY OF THE LISTED______

EQUIV. GENERIC MAY BE USED

Parent/Guardian____________________________Cell#_______________Home#_____________Work#________

Emergency Contacts – Used only if unable to reach parents/guardians

Name_____________________________________Relationship__________________Phone#_________________

Ghs Band Medical Release Form