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STUDENT MEDICAL RELEASE FORM Please print and fill in this form and turn in to Banchi Staff prior to trip!
NAME _______________________________________________________ AGE ________ SEX ________ DATE OF BIRTH _______________________ SOC SEC NO __________________________ ADDRESS ______________________________________________________________ CITY ___________________________________ STATE ____ ZIP __________ HOME PHONE NUMBER __________________________ PARENTS NAMES _________________________________________ PARENTS WORK NUMBERS _______________________________________________________ EMERGENCY CONTACT INFO - NAME _______________________________________________________ PHONE _____________________________________ RELATIONSHIP _______________________________ ADDRESS ______________________________________________________________ CITY ___________________________________ STATE ____ ZIP __________ SPECIFIC ALLERGIES ___________________________________________________________________________________ MEDICATIONS ________________________________________________________________________________________ Asthma:____________ Medications: _________________________________________ Diabetes:____________ Medications: _________________________________________ Epiliepsy:____________ Medications: _________________________________________ Date of Last Teatnus Shot: ______________________ Are there any prescription/non-prescription drugs that should NOT be administered?________________________________________________________________________________ MEDICAL INSURANCE COMPANY_________________________________________________________ ADDRESS ______________________________________________________________ CITY ___________________________________ STATE ____ ZIP __________ PHONE __________________________________ POLICY NO _____________________________________ PHYSICIAN'S NAME _____________________________________ PHONE __________________________________ PHYSICIAN'S ADDRESS ______________________________________________________________ CITY ___________________________________ STATE ____ ZIP __________ I, the parent or legal guardian of ___________________________________(child's name), authorize the chaperones of the _________________________________________(high school and group name) to obtain medical care for my child in the event such necessary care is needed. I understand that if possible, I will be contacted in the event that my child requires medical attention. I grant to a licensed physician or accredited hospital, permission to perform any medical and/or surgical procedures that are essential for the treatment of my child and agree to be responsible for the payment of such care. I release the high school, school district, and its chaperones/employees from any damages, liability or loss resulting from their securing good faith medical care for my child. I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness or injury that he/she may sustain during ski group outings. Parent/Guardian's Signature ____________________________________________________________ Date ____________________ |