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Lake central band
Grade in 2013-2014:
Grimmer Middle School Music Department __ _
Medical Information & Yearly Field Trip Permission Form
I, (We) ________________________________ and _________________________________, residing at Street __________________________________ City ________________________ IN, Zip ___________ As parent(s) or legal guardian(s) of _________________________________________, a minor, (Age _____ Birth Date _____________), I (we) do hereby give permission for the above named child to receive any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine. I also agree to my child’s participation in any field trips relating to the Grimmer Music Department. This form will be in effect for all Grimmer Music activities for the period from May 15, 2013 to Aug. 15, 2014. I give authorization to the Music Director and/or their designee to give consent for treatment while my child is participating in any Grimmer Music activity. I, (We) can expect to be notified by the director or his assigned head chaperone in as timely a manner as possible regarding any treatment rendered, covered by this agreement. Parent (Guardian) Home Phone ____________________ Work Phone ________________ Cell ________________ Other emergency contacts: Name Phone Relationship ___________________________________ __________________ ________________________ ___________________________________ __________________ ________________________ MEDICAL HISTORY
Family Doctor ____________________________________________ Phone _____________________
Health Insurance Carrier ____________________________________ Policy No. ________________
Existing medical conditions ______________________________________________________
Regularly taken medications ______________________________________________________
Date of last Tetanus injection or booster ____________________
* PLEASE ATTACH COPY/COPIES OF INSURANCE CARDS TO THIS FORM.
In the event of minor illness or injury I give staff or chaperone permission to administer --
____ First Aide ____ Tums ____ Tylenol ____ Dramamine ____ Ibuprofen ____ Prescription Medication
Signature(s) or Parent(s) or Guardian(s):
_______________________________________ -- _________________________________________
** ATTN – NOTARY: Only 1 parent signature is required for this form, even if there are two
names/signatures shown above. Thank you.
Subscribed and sworn to before this ________ Day of ___________________ 20 ______. Notary Public ______________________________________ Lake County, Indiana My commission expires ______________________.
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