PARENTAL
STUDENTRELEASE FORM
City________________________State______________________Zip
Code__________
Telephone_______________________DOB__________Grade_________Sex_________
Student's Social Security
#._________________________________________________
Medical History (mark if a
problem):
_____Diabetes_____Epilepsy_____Asthma
_____Allergies (i.e.
food,medicine,etc.)_______________________________________
Other Medical
Conditions__________________________________________________
Prescription
Medications___________________________________________________
If needed, mark any of the
over-the-counter medications the student may take:
_____Tylenol_____Cortaid
Cream _____Cough Syrup/Drops_____Ibuprofen _____Pepto Bismol_____Tums______Throat Lozenges_____Benadryl
_____Neosporin
Ointment_____Betadine (to clean cuts)_____Eye Drops
_____Dramamine (for motion
sickness) _____Imodium
I,___________________ (name of parent/guardian) give
permission for Mr.David E.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 liabilty for
decisions made pursuant to their authorization. I have 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__________________________________________
Sworn to and subscribed
before me this__________day of______________,200__
Notary's
signature__________________________commission expires_________