Student Information Sheet (Page 2 of 4) in pdf

APPENDIX B

MEDICAL RELEASE FORM

I, ______________________, being the parent or legal guardian of ________________

(Parent or Guardian)

(Student)

Do hereby give my permission for him/her to travel with the Mandarin Middle

School Band to all band functions for the 2014-2015 school year, hereby

relieving Duval County liability for personal injuries and/or property damages

resulting from or occurring during or in transit to and from Mandarin Middle

School Band Activities.

Further I request that in the event of illness or accident in the course of

such activities measures be instituted without delay, as judgment of chaperones

and/or medical personnel dictates. Further, I hereby give my permission to have

an adult sponsor of the Mandarin Middle School Band take my child to a

medical facility for the necessary care in the event of an emergency or

administer medical treatment. I understand that should this be necessary, I will

be contacted by phone at the earliest possible time. I further understand that I

am financially responsible for any bills incurred from said emergency treatment

and/or doctor’s fees and that the Mandarin Middle School Band will not be held

responsible.

List any allergies that your son/daughter may have:

______________________________________________________________________________

List any medication that your son/daughter is taking:

______________________________________________________________________________

Circle and/or list any nonprescription medication that may be given to your

child by a chaperone: Ibuprofen (Advil) – Acetaminophen (Tylenol) – Aspirin

-Dramamine –Immodium AD –Tums –Rolaids –Benadryl –Sunscreen –Other_______

EMERGENCY INFORMATION

Student Name:________________________ Parent Names:________________________

Home Phone:_________________________ Work Phone:___________________________

Family Doctor:_________________________ Doctor’s Phone:_______________________

Insurance Carrier:______________________ Policy No.:____________________________

Other Person to notify in case of emergency:__________________________________

To the best of my knowledge, the information above is accurate and complete.

_________________________________________

Signature – (Parent or Guardian)

Student Information Sheet Page 2