Student’s Full Name _____________________________________________________________ Date of Birth ________________ Rockdale County High School Band 2010-2011 Medical Release and Information Form Parent’s or Guardian’s Permission and Release
The Rockdale County Board of Education has no responsibility to provide first aid at any Rockdale County High School Band function (rehearsals,
performances, field trips, travel, etc.) and the parents/guardians understand that the risk of injury is assumed by the student and parents when they are executing this form. However, in the event physicians, physical therapists, physicians assistants, nurses, or other persons trained in the
rendering of first aid are available, as volunteers or otherwise, and render aid to any student injured during the course of any such Band activities or travel, then the parents do hereby agree to release, covenant not to institute any suit or claim, waive, indemnify, hold harmless, release, and
discharge the Rockdale County Board of Education, its individual members, agents, employees, and representatives, from any liability arising out of any first aid or immediate treatment of injuries. In addition, the signing parent or guardian authorizes any necessary medical treatment for the
student listed above while participating in any Rockdale County High School Band function. Also, the signing parent or guardian will pay any payment of all charges incurred during this medical treatment (physician, hospital, x-ray, lab, drugs, ambulance, etc.).
I understand that the information on this form will be kept confidential. Only the band directors and medical personnel with a medical need to know
will have access to this information. By signing this form, I give permission for the band directors to share this information with medical personnel which may be needed to care for my child while my child is under the supervision of the band directors.
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HEALTH HISTORY (To be completed by Student and Parents) Please complete the following information to provide the best treatment for your child.
1. Allergies to foods, medications, etc.
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3. Does student carry medication on person? ______ If so, please list:
a. Medication ________________________________ Purpose _____________________________
b. Medication ________________________________ Purpose _____________________________
4. Date of last Tetanus shot _____________________
5. Limited over-the-counter medications are available in the band’s first aid kit. Below is a list of medications
available. Please initial by the drugs your child may be given if necessary:
_____ Ibuprofen (pain reliever, anti-inflammatory) _____ Tylenol (pain relief and fever reducer) _____ Pepto-bismal (GI upsets)
Student Name _________________________________________________________________________ Date of Birth ________________ Rockdale County High School Band Medical Release and Information Form (2010-11) p.2
_____ Primatine Mist, Bronkaid (Inhaler for use in asthma like situations)
6. Name of family physician _____________________________________________ Phone number
7. Name of Medical/Hospitalization Insurance Company ____________________________________________
Policy # ______________________________________ Group # _________________________________
As the parent/guardian of ___________________________, I deem all of the medical history information as accurate. I will update this information as necessary through the school year. Parent/guardian Signature _____________________________________________Date______________________ PLEASE NOTE THAT THIS FORM DOES NOT TAKE THE PLACE OF THE REQUIRED SCHOOL PHYSICAL FORM AS REQUIRED TO PARTICIPATE IN MARCHING BAND. ALL STUDENTS, INCLUDING NON-MARCHERS, MUST HAVE THIS FORM ON FILE IN ORDER TO PARTICIPATE IN FIELD TRIPS OF ANY KIND WITH THE BAND.
Paymaun M. Lotfi, M.D. Richard L. Layfield, M.D. Patients Last Name FT / PT / Retired If the patient is a Minor, Who is authorizing Treatment:/Accepting Financial Responsibility: Primary Care doctor / Referring Physician Name: (Medicare and HMO patients MUST list a Doctors name) Other Referral Source: Pharmacy Name and Phone Number: Auto Accident Workerâ€