2018 Uintah Marching Band Medical Release and Permission Form
IMPORTANT! PLEASE READ: This form must be submitted before May 25th. This Medical / Health form will be kept with the medical kit at all times in case of a medical emergency involving your student. Make sure ALL blanks are completed. If an item does not apply to your student, please put NA in the blank to insure accurate information. Incomplete forms can not be accepted.

Mr. Gibson is a Certified Advanced Emergency Medical Technician for the State of Utah. He will personally see to all medical needs prior to seeking advanced medical help. If emergency care or a doctor are needed the student will be transported to definitive care as quickly as possible and the parents will be notified.

Since medical information is considered privileged information rest assured that this information will be kept private and used only as HIPPA allows. For the safety of your child the more complete this information is the better we can see to his/her care. Not all questions are marked as required to submit the form, but the more you can fill out the better. Be as complete as you can, but if you just don't know leave it blank if it is not required.

Student's Full Legal Name *
Your answer
Student's Date Of Birth *
MM
/
DD
/
YYYY
Gender *
Primary Emergency Contact Person *
Your answer
Primary Emergency Contact Phone Number *
Your answer
Secondary Contact Person
Your answer
Secondary Contact Phone Number
Your answer
List any operations the student has had in the last year.
Your answer
Does the student have any allergies to medications? If So what?
Your answer
List all medications the student is taking
Your answer
Student's Last Tetanus Shot if Known?
MM
/
DD
/
YYYY
Does the Student have a History of the following?
If you marked any above please elaborate.
Your answer
What Other Medical History does the Student have?
Your answer
Please list any medical procedures you would not like performed
For example Blood transfusion, etc.
Your answer
Student's Regular Doctor
Your answer
Doctor's Phone Number
Your answer
Name of Insurance Policy Holder
Your answer
Insurance Company Name
Your answer
Group Number
Your answer
Policy Number
Your answer
List the over the counter drugs you are comfortable with a staff member distributing to your student
If you don't want us to do this leave them blank. We will dispense the dose indicated on the packaging if indicated by you, and needed.
In the event that a serious emergency arises, it may be necessary for a physician to attend to your student before the staff can reach you or your designated physician. Such emergency care can be provided only if you sign the following Authorization to Provide Medical Treatment. (All information above is required for emergency treatment of your student). AUTHORIZATION TO PROVIDE MEDICAL TREATMENT I hereby give the band director or chaperone in charge of my son / daughter limited power of attorney to act in my absence and see that ________________________________ (student’s name) receives whatever medical treatment is necessary in the event of an emergency.
Parent / Guardian Name *
Your answer
Parent Electronic Signautre *
By typing your name here you are signing this document and indicating that it is full and complete to the best of your knowledge.
Your answer
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