STUDENT:____________________________GUARDIAN/PARENT___________________________________

HOME ADDRESS:____________________________________________________________________________

TELEPHONE: HOME: ( )______________WORK ( )______________ CELL ( )_____________________

EMERGENCY CONTACT:_________________________________

OVER THE COUNTER AND/OR PRESCRIPTION MEDICATIONS:

_____________________________________________________________________________________

ALLERGIES/MEDICAL CONDITIONS/SPECIAL INSTRUCTIONS:

_____________________________________________________________________________________

MEDICAL INSURANCE INFORMATION:

INSURANCE CARRIER:_______________________________________

POLICY NUMBER:___________________________________________

POLICY HOLDER’S NAME ____________________________________

INSURANCE ADDRESS:_______________________________________

TELEPHONE NUMBER:_______________________________________

BY SIGNING THIS FORM I HEREBY GIVE MY PERMISSION FOR MY CHILD_____________________________________ TO PARTICIPATE IN ALL ITAWAMBA HIGH SCHOOL SPONSORED BAND ACTIVITIES. I UNDERSTAND SUCH ACTIVITIES MAY REQUIRE TRANSPORTATION OF MY CHILD TO LOCATIONS AND SCHOOLS OTHER THAN ITAWAMBA HIGH SCHOOL. BY ALLOWING MY CHILD TO PARTICIPATE IN BAND ACTIVITIES AS INDICATED ABOVE, I AGREE TO RELEASE FROM LIABILITY AND HOLD HARMLESS ITAWAMBA HIGH SCHOOL, ITAWAMBA COUNTY SCHOOL BOARD, ITAWAMBA COUNTY PUBLIC SCHOOLS AND ITS EMPLOYEES, FROM ANY AND ALL PERSONAL INJURY AND/OR PROPERTY DAMAGE OR LOSS WHICH MAY OCCUR AS A RESULT OF MY CHILD’S PARTICIPATION IN BAND ACTIVITIES.

IN THE EVENT I CANNOT BE REACHED IN AN EMERGENCY AFTER REASONABLE EFFORT, AND IF SCHOOL AND/OR MEDICAL PERSONNEL DEEM IMMEDIATE TREATMENT IS MEDICALLY NECESSARY TO PREVENT FURTHER INJURY OR DEATH, I AUTHORIZE SCHOOL AUTHORITIES TO TRANSPORT OR PERMIT MY CHILD TO BE TRANSPORTED TO A MEDICAL FACILITY FOR TREATMENT.

I HEREBY AGREE TO ASSUME FULL FINANCIAL RESPONSIBILITY FOR PAYMENT OF EMERGENCY MEDICAL SERVICES RENDERED UNDER CIRCUMSTANCES FOR TREATMENT.

MY SIGNATURE BELOW INDICATES I AM THE PARENT, OR GUARDIAN OF THE ABOVE-NAMED CHILD AND THAT I HAVE READ AND UNDERSTOOD THIS EMERGENCY AUTHORIZATION AND RELEASE FROM LIABILITY FORM.

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SIGNATURE OF PARENT/GUARDIAN                                                         DATE

 

PLEASE RETURN THIS FORM TO THE BAND DIRECTOR "no later than July 29th, 2011"!