Medical_form 2010-11[1]

Regarding: The Bolton High School Band Events for the 2010-2011 school year

Name (one form per student)____________________________________________________
City_________________________ State ________________ Zip Code __________________
Telephone___________________ DOB________________ Grade_______ Sex __________
Email Address ________________________________________________________________
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
____ Throat Lozenges
____ Sudafed
____ Benadryl
____ Neosporin Ointment
____ Imodium
____ Eye Drops
____ Betadine (to clean cuts)
____ Dramamine (for motion sickness)
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 liability 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___________________________________________________
Emergency Phone Numbers ____________________________________________________

Sworn to and subscribed before me this _______ day of _______________, 200____
Notary’s signature_________________________ Commission expires____________


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