Lake View Chieftain Band - Release/ Info Form 2024-25

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Email *

Student Name *

Parent's/Guardian Name(s) *

Home Address *

Parent's/Guardian Phone *

Student Cell Phone

Shirt Size *

XXL

Shoe Size (specify male or female) *

Parent e-mail *

Family Physician

Medical Information

Any known Allergies? *

Any physical problems? *

Taking any medication(s)? *

Any other medical problems? *

Sponsor may give my child:

Aspirin *

Yes

Ibuprofen *

Yes

Tylenol *

Yes

Pepto-Bismol *

Yes

Other

Insurance Information:

Company

Policy Number

By choosing yes, I give my permission for my child to participate with the Lake View Band in any planned activity during the 2024-25 school year. I give my permission for a Director or any other adult person acting as co-sponsor on the trip to secure emergency medical aid for my child. I agree that any medical expenses incurred for any reason are my responsibility. I release San Angelo ISD, Lake View High School, and any adult sponsor from all responsibilities due to accident or illness incurred during this trip. *

Yes

A copy of your responses will be emailed to the address you provided.

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