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Microsoft word - 9-2010 medical release form.doc

PARKVIEW HIGH SCHOOL BAND
MEDICAL RELEASE FORM
2010 - 2011
STUDENT CONTACT INFORMATION: (All information is required, please print legibly)
Student’s Last Name:
First Name:
Nickname:
Gender: F M
Student #:
Guard Only (no
Band Class (circle one)
Concert 1
Concert 2
Symphonic
Concert Instrument:
Marching Instrument:
Instrument Group:
Marching
Alternate Officer Position:
Mom’s Name:
Dad’s Name:
Home Phone:
Mom Work:
Dad Work:
Cell Phone:
Student:
Student:
EMERGENCY CONTACT INFORMATION: (All information is required)
Emergency

Relationship:
Contact:
Doctors Name
Insurance Carrier:
Policy #:
MEDICAL INFORMATION: (Check all boxes and list concerns, if applicable)
My child has special needs or concerns (include any current medications with dose and side effects or any
other preferred over the counter medication that can be given to them (such as Motrin, Aleve, Midol, etc):


My child is ALLERGIC to:


My child may take (without further permission, check all that apply) :

Advil Tylenol Pepto Bismol Benadryl
PARKVIEW HIGH SCHOOL BAND
MEDICAL RELEASE FORM
2010 - 2011
PLEASE SIGN AND DATE BOTH STATEMENTS.
ME DICAL DISCLAIMER: This must be completed for every student.
I a gree to assume responsibility for any unforeseen accident that might occur during travel or participation in this activity. I also authorize any emergency medical treatment that may be necessary. I hereby give permission to the Band Chaperones and staff to administer over the counter medications as directed above during Band Activities. The Parkview Band hosts a number of social events throughout the year, (Back to School Pool party, Band Lock-in, Parties, etc.). Since these are not official “school” activities, we require additional written parental consent to allow a student to participate. Please read and sign the statement below. This statement will allow student participation in any of our band social events. I the Undersigned, as natural parent or custodial guardian, grant permission for (student’s name) _________ _________________________ , a minor and hereinafter referred to as “permittee”, to attend PHS Band related social activities. Should immediate medical attention be needed for the permittee due to either accident or illness, I grant a representative of the Parkview Band permission to obtain such medical treatment as is required. In consideration for permission to attend a Band social activity, I waive any and all claims for myself, permittee, and my and permittee’s heirs against the Parkview Band Association, its officers, directors, and volunteers for any injury or illness which may directly or indirectly result from permittee's attendance at or participation in the above described Band social activities. I further certify that permittee is in proper physical and emotional condition to attend and participate in said Band social activity. I understand that should immediate medical attention described above be needed, attempts to notify me will be made as soon as possible but the first concern is the health of my child. Parent/Guardian Signature:

Source: http://www.parkviewband.net/forms/10-11/9-2010%20Medical%20Release%20Form.pdf

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Pragnesh Patel, M.D. Office Address Wayne State University University Health Center 4201 St. Antoine (Pod 5C) Detroit, MI 48201 (313) 577-5030 Education & Training 8/2004 –7/2005 Fellowship: Wayne State University Geriatrics/Internal Medicine Detroit, MI 8/2004 – present 1998 – 2000 Residency: St. John Hospital & Medical Center Detroit, MI 1997 – 1998 Inter

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Robert L. Findling, M.D., M.B.A. Rocco L. Motto, M.D. Chair of Child and Adolescent Psychiatry Professor of Psychiatry & Pediatrics Director, Child & Adolescent Psychiatry University Hospitals Case Medical Center Education: International MBA: London School of Economics, London, UK; New York University, New York, NY; HEC, Paris, France Medical school: Medical College of Virginia,

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