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 ______