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 address *
Student LAST NAME *
Your answer
Student FIRST NAME *
Your answer
Parent/Guardian LAST NAME *
Your answer
Parent/Guardian FIRST NAME *
Your answer
Parent Cell Phone Number *
Your answer
Student Cell Phone Number *
Your answer
Emergency Contact NAME *
Your answer
Emergency Contact PHONE NUMBER *
Your answer
Emergency Contact Relationship to STUDENT
My student suffers from the following chronic conditions and/or allergies: (Please list any allergies to specific medications as well) *
Your answer
My student requires the following prescription medications. (if none, just put N/A) *
Your answer
Please list the frequency of needing to administer the prescribed medications (once daily, twice daily, etc)
Your answer
Name of Primary Insurance *
Your answer
Insurance Policy Number *
Your answer
Insurance Contact Phone Number *
Your answer
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