Shelbyville High School Band Medical Form
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III. MEDICAL INFORMATION/PERMISSIONS 2022-2023 School Year
ACTIVITIES - SHS Band rehearsals and trips to band days, parades and other events scheduled during school year
Student's Full Name *
Student's Address *
City *
State *
Zip Code *
Students Passport Number (if applicable)
Mother's Name
Father's Name
Home Phone *
Cell Phone *
Mother's Work Phone
Father's Work Phone
Emergency Contact #1 Name *
Emergency Contact #1 Phone *
Emergency Contact #2 Name *
Emergency Contact #2 Phone *
Medical Information*
*Send additional information to SHS Band Department if needed
Medication #1 taken?
Medication #1 dosage?
Medication #2 taken?
Medication #2 dosage?
Any allergies or other conditions?
In case of an emergency, the teacher/chaperone is authorized to act as a temporary guardian of my child and to seek appropriate medical treatment: *
As these trips are part of the Corporation’s educational program and provide experiences of educational value, all school rules apply. All rules violations will be dealt with upon return to school. Should the rules violation, in the judgment of the teacher/chaperone, warrant immediate action, the teacher/chaperone may take any actions they deem reasonable and necessary including, but not limited to sending the student home at his/her own expense.
It should be understood that the activities associated with these trips are such that students cannot be supervised by school staff at all times. While this trip will be supervised and there will be specific guidelines for behavior, students may be permitted to be in places where the supervisor cannot see them or contact them directly
PARENTAL AUTHORIZATION: My child has permission to participate in the school-sponsored activities above. I also understand that my child may be photographed or recorded on video as a part of this school-sponsored group. I give permission for my child to be photographed or video recorded and for his/her image to be used for non-commercial, educational purposes, including promotional materials for this group.
Medical Consent:  Parents Signature #1 (by typing your name here you are agreeing to the above terms and conditions on this form and that the information provided is accurate) *
Date *
MM
/
DD
/
YYYY
Medical Consent:  Parents Signature #2 (by typing your name here you are agreeing to the above terms and conditions on this form and that the information provided is accurate)
Date #2
MM
/
DD
/
YYYY
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