Aledo Band Medical History and General Waiver

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2021-2022 School Year

Last Name *

First Name *

Date of Birth *

YYYY

Other:

Parent (Guardian) Name *

Parent Phone Number *

Primary Email Address *

Alternate Contact Name *

Alternate Contact Phone Number *

Physician Name *

Physician Office Phone Number *

Insurance Company *

Policy # *

Insurance Phone Number *

Medical History (Has your student ever experienced a medical problem associated with any of the following?) Check all that apply.

Asthma

Allergies

Diabetes

Seizures

Broken Bones

Head Injury

Back Injury

Heat Related

Heart Condition

Blood Pressure

Abnormal Bleeding

Blood Disorder

Hearing Loss

Vision Problem

Cancer

Previous Surgery

Other

Medical History : Please provide specific details regarding checked items above:

Please specify any medications which your student takes on a regular basis. Include the medication name, dosage, and frequency.

Allergies : Is your child allergic to any medication? (Please list.) Any other items? (Please list.)

Please indicate which of the following over the counter medications that you approve to be dispensed to your student at the discretion of a band director or designated chaperone.

Ibuprofin

Tylenol

Benadryl

Pepto Bismol

Sudafed

Tums

Neosporin

Hydrocortisone

Row 1

Anything else we may need to know:

Student Name *

The named Student is my child, and is now under my control and in my custody. The undersigned agrees to be responsible for the safe return of all band equipment issued by the school to the above named student. I desire such child to go on any and all trips, and participate in any and all activities. I understand that normal precautions will be taken in the interest of my student's safety and well-being. If, in the judgement of the activity sponsor, the above student needs immediate care and treatment as a result of any injury or sickness, I do hereby agree to indemnify and save harmless the school, activity sponsor or school representative from and claim by any person whomsoever on account of such care and treatment of said student. *

I agree to Sign and Submit electronically.

Required

Parent / Guardian Signature (by typing my name I agree to submit my signature electronically.) *

YYYY

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