WEBB CITY CARDINAL PRIDE

JUNIOR HIGH STUDENT INFO MEDICAL RELEASE FORM HANDBOOK ACKNOWLEDGEMENT Student Information Name:

Grade:

Address:

Cell Ph:

DOB: Text: Y N

Home Ph: Parent/Guardian Information Name:

Name:_

Address:

Address:

Home Ph:

Home Ph:

Work Ph:

Work Ph:

Cell Ph:

Cell Ph:

Emergency Contact #1 (non-parent)

Emergency Contact#2 (non-parent)

Name:

Name:

Home Ph:

Home Ph:

Work Ph:

Work Ph:

Cell Ph:

Text: Y N

Cell Ph:

Medical Information Please list any chronic conditions your student may have (Asthma, headaches, etc.) Please list any allergies your student may have (penicillin, peanuts, Milk, etc.) Please list all medications and dosages your student takes regularly (inhalers, etc.) Please indicate if your child will need special meals when with the band (vegetarian, etc.)

PLEASE SEE OTHER SIDE FOR INSURANCE, SIGNATURE, AND DATE

Text: Y

N

Insurance Information (Optional)**** Personal Insurance Provider:

Policy #

Family Doctor:

Dr. Ph: Medical Treatment Consent

The undersigned parent or guardian assumes responsibility for the student while they are on the trip with the understanding that the undersigned be notified immediately should anything unforeseen occur to the student. In the event the band staff/nurses/chaperones are unable or shall not have sufficient time in which to locate the undersigned in case of emergency, then the band staff/nurses/chaperones may take such temporary measures, as they deems appropriate for the welfare of the student, including medical and hospital services. The undersigned or the medical insurance company of the undersigned agrees to pay all medical expenses incurred by the student. It is also the responsibility of the undersigned to come to the band office where this form will be kept to make any changes and update information as needed. Signed

Parent/Guardian Signature

Date

****Please attach a copy of the student’s insurance card, if possible.

Band Handbook Acknowledgement We (the Band Member and Parents/Guardians) have read and understand all of the information regarding the WCJH Band Handbook and agree to follow the expectations of the Cardinal Pride Band Program. Further, we understand that it is our responsibility to get information updated on Charms and will be proactive in checking Charms for information. If we do not have access to electronic communication, we will be responsible for getting and providing information in another way. Signed:

Signed:

Parent/Guardian Signature

Band Member Signature

Date

Date