Medical Release Information
This information is required to be carried by the band director in case of an emergency while your student is participating in a Del Mar High School Performing Arts activity, performance, rehearsal, tour or other event. This information will be kept confidential by the Band Director and the Del Mar staff who may have access in order to provide care for your student in the event of an emergency.
Student LAST NAME
Student FIRST NAME
Parent/Guardian LAST NAME
Parent/Guardian FIRST NAME
Parent Cell Phone Number
Student Cell Phone Number
Emergency Contact NAME
Emergency Contact PHONE NUMBER
Emergency Contact Relationship to STUDENT
Other Parent/Step Parent
Other Relative (Aunt, Uncle etc)
Family friend who is fully authorized to act on parent's behalf
My student suffers from the following chronic conditions and/or allergies: (Please list any allergies to specific medications as well)
My student requires the following prescription medications
Please list the frequency of needing to administer the prescribed medications (once daily, twice daily, etc)
Name of Primary Insurance
Insurance Policy Number
Insurance Contact Phone Number
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This form was created inside of Campbell Union High School District.