Microsoft word - medical release form

STUDENT NAME ________________________________________________________________ BIRTH DATE _____/_____/_________ I, the undersigned, being the parent, legal next-of-kin, or legal guardian of _____________________________________, hereby authorize any necessary medical treatment for this person while participating in any South-Doyle High School Band functions during the 2011-2012 school year. I also will be responsible for all financial responsibilities during medical treatment. In regard to such person, I submit the following information: 1. Allergies to foods, medications. If none, write “none”. ____________________________________________________ ____________________________________________________________________________________________________________________________ 2. Special medical problems or health conditions. If none, write “none”. ___________________________________ ____________________________________________________________________________________________________________________________ 3. Medication(s) or prescription(s) to be used by student. If none, write “none”. Medication ___________________________________________ Purpose _______________________________________________ Medication ___________________________________________ Purpose _______________________________________________ Medication ___________________________________________ Purpose _______________________________________________ In the event that we cannot reach you, do we have permission to give any of the following medicines to your child? (Please mark yes or no for each line) My child is prescribed and carries: an Epi Pen Yes _____ No _____ an inhaler Yes _____ No _____ Date of last Tetanus shot? _____________________________________________ Family Physician _______________________________________________________ Phone _________________________________ Person(s) other than parent or guardian to notify in case of emergency: Name __________________________________________ Phone ___________________ Relationship ________________________ Name __________________________________________ Phone ___________________ Relationship ________________________ Health Insurance Carrier ________________________________________ Policy Group # _____________________________ Policy Holder’s Name ____________________________________________ ID # _______________________________________ I hereby give permission and approval for any and all medical and surgical treatments, including anesthesia and operations which may be necessary and or available to my son or daughter by the attending physician and surgeons. The intention hereof, being to grant authority to administer and perform all and singularly, and procedure which may now or during the course of the patient’s care be deemed advisable or necessary. I/we also agree that the patient, when admitted, is to remain in the hospital until his/her physician recommends the patient’s discharge. Every effort will be made to contact parent(s) or guardian(s) in advance of treatment, by telephone, in case of injury or illness Parent/Guardian Signature ____________________________________________________ Date __________________________ Notary Public ________________________________________________ Date _____________________ Expire _______________

Source: http://www.southdoyleband.org/downloads/forms/Medical%20Release%20Form-2011.pdf