TEMPORARY MEDICAL GUARDIANSHIP
ALL BAND/ALL GUARD PARTICIPANTS
Student's Name
Your answer
Date of Birth
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Grade
TO WHOM IT MAY CONCERN: I (we) the undersigned, _________________________________________________, are the natural parents or legal guardians of _____________________________________________________. During our absence he/she has been placed in the temporary care of Little Elm High School Band , who is/are empowered by this statement to call for and authorize medical care and assistance in the event of injury, accident or illness involving our child or children. It is my (our) intention that this statement serve as authorization for such medical care to be administered during the following period of time: Beginning Date 1 August 2017 through the Ending Date 1 August 2018 .
Please type the name of the parent, followed by the name of the student. (Ex. JOHN SMITH, TANNER SMITH)
Your answer
In the event that further medical consultation is required, the physician who has most recently examined the child/children is:
Please list both the name and phone number of the physician.
Your answer
Known Allergies:
Please list any drug and/or food allergies
Your answer
Last Tetanus:
Please list the latest date of receiving a tetanus shot.
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List all medical conditions, history of surgeries, and serious injuries:
Your answer
List names and doses of all regular medications:
Your answer
In case of emergency, the following person/people is/are also authorized to give consent for treatment if the parent/legal guardian cannot be reached:
Please list all name(s), relationship, phone number(s), and email addresses.
Your answer
Parent/Legal Guardian:
Your answer
Parent/Legal Guardian Signature:
Your answer
Signature Date:
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Emergency Contact Numbers for PARENTS:
Include home, work, and cell phone contact numbers.
Your answer
PRIVACY STATEMENT
For your information, please be advised that all information on this form will only be used to assist in obtaining emergency medical treatment. I have read and understand the above Privacy Statement.
Required
Parent/Legal Guardian Signature*
Final Signature*
Your answer
Parent/Legal Guardian Signature Date*
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Student Signature*
Your answer
Student Signature Date*
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