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Medical and permission form

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

Source: http://woodmontband.files.wordpress.com/2012/02/medical-and-permission-form-2012.pdf

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