Student Name______________________ Page 1 of 2 Parents Initials_____________________ School Year 2011-2012 Rev. 1
Woodmont High School Band Permission Form
Section 1: Permission to Participate/Travel
My son/daughter __________________________________ has my permission to participate in the activities of the Woodmont High School Band. These activities include rehearsals, performances, and transportation to and from performances. Performances will include football games, parades, contests, concerts, and other events at the request of the director and/or principal.
Section 2: Emergency Contact Information
Parent Name(s) ____________________________ Parent Home Number_______________ Parent Cell Number______________________ Parent Work Number___________________ Home Address ______________________________________________________________ Email Address(es)____________________________________________________________ Student’s Primary Doctor (name, phone, address) __________________________________ ___________________________________________________________________________ Insurance Information (Carrier Name, ID #, Group #, Policy #, phone): ___________________________________________________________________________ Please list at least one other person that we can try to contact, if we cannot reach you during an emergency. Name ____________________________________________________________________ Relationship _______________________Phone Number(s) __________________________
Section 3: Medical Limited Power of Attorney
If a serious emergency arises, it may be necessary for a physician to attend to your son/daughter before the staff could get in touch with you or your designated physician. Such care can be provided only if you sign the following AUTHORIZATION FOR MEDICAL TREATMENT. I give the teacher or administrator in charge of my son/daughter limited power of attorney to act in my absence and see that my daughter/son __________________________ gets whatever medical treatment necessary in case of sickness or accident.
Section 4: Emergency Medical Information
The local emergency room assisted with this list If your child’s information changes, please be sure to update this form. Date of birth: __________________ Date of last Tetanus shot: _____________________ List any medical history that your child may have. Please include dates. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List any surgeries that your child has had. Please include dates. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List any allergies that you child may have. Please include allergies to medicines, insects, food or contact allergies. __________________________________________________________________________________________ __________________________________________________________________________________________ List any medicine prescribed by a doctor that you child is currently taking. Please include the name, the dosage, and the frequency that the medicine is taken.
Student Name______________________ Page 2 of 2 Parents Initials_____________________ School Year 2011-2012 Rev. 1
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Section 5: Permission to Dispense Over the Counter Medicine
Over the Counter Medication (OTCs): If students become ill on a trip, the booster club will keep a limited supply of OTCs to make them comfortable until we return, or until a parent arrives. Below are the OTCs we try to have on hand. Brand names are for reference. We use mostly generics to keep costs down. A staff member or chaperone controls these supplies, and a record is kept when they are dispensed. If there are any OTCs that you do not want your child to have, please check the NO column. OTCs will be dispensed in the amount and at the frequency specified on the container. Item
Acetaminophen pain reliever/fever reducer
Diphenhydramine HCL – allergic reaction
Sun Screen – Each student is responsible for his/her own sunscreen. We will
have a bottle on hand in case someone forgets. Prescription Medication: If you would like to send prescription medicine for the staff/chaperones to hold for your child, a locked first aid case will be carried on trips. You must send the medicine in the original container with your child’s name and prescription details such as medicine name and dosage clearly marked. Any unused prescription medicines can be picked up at the end of the season. If your child uses an inhaler or epipen, you are encouraged to send a spare for us to keep on hand. Social Security Number: In a medical emergency, medical health professionals will eventually need your child’s SSN. Please make sure that both you and your emergency contact have that number. The original of this form will be kept at the high school. Copies will be taken on each trip. If your child requires medical attention, a copy may be given to the medical staff treating your child. THIS FORM MUST BE NOTARIZED _________________________________________ _______________________ Signature of Parent Legal Guardian Date State of South Carolina, County of Greenville Sworn to and subscribed before me this ____________ day of____________________, 20__ _________________ ____________________ Notary Public of South Carolina My Commission Expires
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N.B. Koorts is een symptoom. Oorzaak aanwijzen voordat je hem behandelt. Daarnaast is het wel zo dat gezonde mensen meestal geen antibiotica nodig hebben om een koortsende ziekte te overwinnen. Bovendien betreft het in die groep mensen vaak een griepsoort, en op virusinfecties hebben antibiotica toch geen invloed. Milde pijnstiller, tevens bruikbaar om koorts te drukken indien die als hinderlij