Medical Band Form 2020
PIEDMONT HIGH SCHOOL
THE PRIDE OF PIEDMONT
Emergency Release Form
2020 Marching Season

I (parent/guardian) give my permission to the Band Directors of Piedmont High School to act as a guardian in the event of an accident involving my child until I am able to be contacted. Also, in the event of an emergency, he/she has my permission of consent to the attending physician/emergency response team to administer any medications or perform any treatments that he/she deems necessary for the proper care and well-being of my child until I am able to be contacted.
Student FIRST Name *
Student LAST Name *
Mother/Guardian Full Name *
Write N/A if does not apply to you.
Mom's Home Phone
xxx-xxx-xxxx
Mom's Cell Phone
xxx-xxx-xxxx
Mom's Work Phone
xxx-xxx-xxxx
Father/Guardian Full Name *
Write N/A if does not apply to you.
Dad's Home Phone
xxx-xxx-xxxx
Dad's Cell Phone
xxx-xxx-xxxx
Dad's Work Phone
xxx-xxx-xxxx
Emergency Contact Name *
Emergency Contact Phone *
xxx-xxx-xxxx
List any medical alerts such as allergies, medicines, or any other medical concerns. *
Write N/A if does not apply to you.
Parent/Guardian Signature *
By providing your electronic signature below, you agree that this can be used in the same manner as a physical signature.
*
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