Medical Form and Agreement Form

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Student Last Name *

Student First Name *

My child has my permission to participate in any band activity required by the band director. *

Yes

Required

List any physical restrictions (if any) below:

List any allergies that may affect participation, especially during marching season:

List restrictions (if any) to medication that may be dispensed for headache, colds, sore throat, etc.

Parent Full Name *

I give permission for my child to receive emergency medical treatment in case of illness or injury. I further understand that I am responsible for any medical expenses not covered by medical insurance. I agree not to hold Shelbyville CentralHigh School, the Shelbyville Central High School Band, the Director and Staff of theSCHS Band, and/or the Bedford County Board of Education responsible for injuries incurred during a band activity.

Parent Full Name

I/We, (parents), have read the rules and procedures in this handbook and agree to comply with them. I agree not to hold Shelbyville Central High School, the Shelbyville Central HighSchool Band, the Director and Staff of the SCHS Band, and/or the BedfordCounty Board of Education responsible for injuries incurred during a band activity.

Parent Full name

My child has my permission to travel by bus to the away games and contests and other band events that are scheduled for this year.

Parent Work Phone *

Parent Cell Phone *

Insurance Company *

Policy Number *

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