Medical Release Form 2019
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.
Email *
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
Clear selection
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. (if none, just put N/A) *
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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