Medical Form
East Rutherford High School Band
Consent for Medical Treatment
TO WHOM IT MAY CONCERN, I, the undersigned parent or guardian of:
_______________________________ _______________________
Name of Student Date of Birth
hereby grant permission to the band director or any chaperone of the East Rutherford High School Band Boosters standing in loco parentis to obtain any emergency medical and/or surgical procedures from a physician or hospital emergency room physician on behalf of the above-named minor.
Signature______________________________________ Date_____________________
Parent’s Printed Name ____________________________________________________
GENERAL INFORMATION
__________________________________________ ____________________________
Student Phone
Address:
Street ____________________ City ___________________ State ______ Zip ___________
Father’s Name ________________________________ Business Phone ________________
Place of Business _________________________________ Title ______________________
Mother’s Name ________________________________ Business Phone _______________
Place of Business _________________________________ Title ______________________
ALTERNATE TO NOTIFY IN CASE OF EMERGENCY
Name _____________________________________ Relationship ____________________
Phone ____________________ City ___________________ State ______ Zip ___________
Financial Considerations
For and in consideration of emergency services and goods rendered by or through the attending physician(s), the undersigned hereby guarantees payment immediately upon receipt of final billing.
Signature ___________________________________________ Date____________________
MEDICAL INFORMATION
Student _______________________________ Sex: M F Birth Date _________________
Insurance Carrier ______________________________ Policy Number _________________
Parents _____________________________________________________________________
Please complete the questions below. It is imperative that we have medical information to care for the student in case of emergency.
Does the student have chronic health problems?
Is the student allergic to any medicines?
Does he or she have allergies?
What is the date of the student’s last tetanus shot?
Please list any additional pertinent information.
Family Physician
____________________________________________________________________________
Telephone and Address
____________________________________________________________________________
In case of minor illness, the East Rutherford High School band director or chaperones of the band boosters have my permission to give over-the-counter drugs such as Tylenol, Maalox, Sudafed, Ibuprofen, or Dramamine to my son or daughter.
Yes ______ No ______