Sherando High School Band 2023-2024           Emergency Contact / Medical Information Form
In the rare event of an emergency or concern (medical or otherwise), it may be necessary to contact you or a person authorized to act on your behalf.  By signing below, you give the directors, staff, and adult chaperones authority to obtain any medical services deemed immediately necessary by attending physicians and agree to be financially responsible for any expenses incurred.  The directors, staff, and chaperones will use their best judgement and will act in the best interest of the good health of the student and the group.

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Email *
Student Name: *
Parent/Guardian Name: *
Mailing (Physical) Address: *
Home Phone: *
Work Phone: *
Cell Phone: *
In the event that I cannot be immediately contacted, the following individuals are authorized to act on my behalf:  (Please list the individual's NAME, PHONE, and relationship to student's family) *
Insurance Company (if you would like to list this): *
Insurance Policy Number (if you would like to list this): *
Allergies or Conditions of which you would like to make us aware: *
Please list any medications taken: *
If considered necessary by the directors or chaperones during band trips, my child may be given appropriate over-the-counter medications such as pain relievers, antihistamines, decongestants, upset stomach relief, etc. *
My child should NOT be given the following: *
Parent/Guardian - Electronic Signature (please sign with your full name, make sure this matches the email user listed above) *
Date: *
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YYYY
Please use this section to communicate any additional information that you wish for us to have, such as current injury situations, etc.   
A copy of your responses will be emailed to the address you provided.
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