Scribd Logo
Upload

Welcome to Scribd!

  • Medical Form

    Uploaded by

    Дария Коваленко
    25 views1 page

    Original Title

    Medical+Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    25 views1 page

    Medical Form

    Uploaded by

    Дария Коваленко

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    of 1
    PARENTAL STUDENT RELEASE FORM Regarding: The Bolton High School Band Events for the 2011-2012 school year ‘Name (one form per student) Address City. State Zip Code Telephone, DOB. Grade, Sex Email Address Student's Social Security # Medical History (mark if a problem): ___Diabetes __ Epilepsy Asthma —~ Allergies (ie., food, medicine, ete.) Other Medical Conditions Prescription Medications Please mark any/all of the over-the-counter medications the student may take: __ Tylenol __ Cortaid Cream _ Cough Syrup/Drops ___ Ibuprofen ___ Pepto Bismol ___ Throat Lozenges __ Sudafed —— Benadryl == Neosporin Ointment Imodium —_ Eye Drops —— Betadine (to clean cuts) Dramamine (for motion sickness) L (name of parent/guardian) give permission for Mr. David B. Chipman, Director of Bands, or any adult named by Mr. Chipman to act in my behalf to approve appropriate medical treatment for my son/daughter should an emergency medical treatment be necessary and will make any necessary financial reimbursements. I further state that I am of lawful age and legally competent to sign this Medical Release; that I understand that the terms herein are contractual and are not a mere recital; and that I have signed this document as my own free act. I agree to release and hold harmless Mr. Chipman or his nominee from any liability for decisions made pursuant to their authorization. Ihave fully informed myself of the contents of the Medical Release by reading it and that the medical and insurance information I give below is accurate. Name of Insurance Company, Account Number. Doctor’s Name & Phone_ Signature of Parent/Guardian, Emergency Phone Numbers (Home) (Work) (Cal Sworn to and subseribed before me this day of +20. Notary’s signature, Commission expires.

    You might also like