Leigh medical release form

LEIGH PERFORMING ARTS
MEDICAL INFORMATION / PARENT CONSENT
**ALL INFORMATION GIVEN WILL REMAIN CONFIDENTIALLY ON FILE UNTIL DESTROYED AT THE END OF THE SCHOOL YEAR** _________________________________________________________________________________________________ STUDENT’S DOB: ________/________/________ CITY & STATE OF BIRTH: _________________________________ STUDENT’S ADDRESS: __________________________________ CITY & STATE: ______________________________ HOME PHONE: __________________________________ CELL NUMBER: __________________________________ PARENT/GUARDIAN INFORMATION:
FATHER’S NAME: __________________________________ MOTHER’S NAME:______________________________ FATHER’S WORK:__________________________________ MOTHER’S WORK: _____________________________ WORK PHONE: ____________________________________ WORK PHONE:_________________________________ ALT. PHONE: ______________________________________ ALT. PHONE: __________________________________ EMERGENCY CONTACT INFORMATION (REQUIRED):
NAME & RELATIONSHIP: __________________________________________ PHONE: _______________________ FAMILY DOCTOR NAME: __________________________________________ PHONE: _______________________ SPECIAL MEDICAL NEEDS, HEALTH PROBLEMS, PHYSICAL RESTRICTIONS (IF NONE, WRITE NONE): __________________________________________________________________________________________________ ALLERGIES TO FOOD, MEDICINE, INSECT STINGS, ETC (IF NONE, WRITE NONE): __________________________________________________________________________________________________ CURRENT MEDICATION BEING TAKEN * (IF NONE, WRITE NONE): __________________________________________________________________________________________________ *Students taking medications on a regular basis are required to turn in these medications to he held in a secure place on any extended trip. A complete list of the student’s medications and when they are to be taken must be included. Medications must be in the original prescription container. Students wil be able to take their medications as needed. If your child uses an inhaler, please have them carry it at al times. PARENT CONSENT:
I am aware of my child’s participation in the 2012-2013 LHS MARCHING BAND AND COLOR GUARD with
LEIGH HIGH SCHOOL PERFORMING ARTS. I am aware that taking part in this activity carries the risk of injury
to my child, particularly due to travel, practice and performance. The directors, instructors, sponsors, and
parents/chaperones have my permission, in an emergency situation when I cannot be contacted, to seek medical
assistance at a medical clinic or hospital emergency room at my expense. I certify that I have adequate
insurance coverage as stated below and I accept ful responsibility for any medical expenses arising due to the
injury or il ness of my child while participating as a member of the organization.
PARENT/GUARDIAN SIGNATURE: ____________________________________ DATE: _________________ PRINTED NAME OF POLICY HOLDER: ________________________________________________________ INSURANCE COMPANY: _________________________________________________________________ POLICY NUMBER: __________________________ GROUP NUMBER: ____________________ **WE MUST HAVE A COPY OF YOUR INSURANCE CARD TO KEEP ON FILE WITH THIS FORM**
AUTHORIZATION TO TREAT A MINOR
I (we), the undersigned parent/guardian of ____________________________________________________ , a minor, do hereby authorize and consent to any medical treatment rendered under the general or special supervision of any member of the medical profession and emergency room staff. I give my permission to directors, instructors, sponsors, and /or chaperones to administer over the counter drugs and first aid for emergency use only. I have indicated below what medications can be given to my child. Those administering the treatment wil fol ow the directions on the medication unless otherwise noted in the child’s medical form. Please initial next to what your child can be given in an emergency. (Emergencies wil be determined by the director/instructor/sponsor/chaperone.) Medications listed could be a variation of the specific brand name or a generic brand. ________ Tylenol ________ Advil _________ Imodium ________ Benadryl ______Tums ________ Dramamine ________ Pepto-Bismol ________ Cough Drops _________Aspirin _______ Sudafed _______ Aleve __________________________________________________________________________________________ List any restrictions:____________________________________________________________________________ PARENT SIGNATURE: _________________________________________________ DATE: ___________

Source: http://leighpapa.org/site/wp-content/uploads/2012/07/Leigh-Medical-Release-form.pdf