FOLEY HIGH SCHOOL BAND
MEDICAL INFORMATION AND CONSENT FORM
This complete form must be signed before a notary public.

STUDENT NAME_________________________________________HOME PHONE________________

ADDRESS_____________________________________CITY______________________ZIP__________

PARENT/GUARDIAN_____________________________________

EMPLOYER______________________________________________WORK PHONE________________

CELL PHONE_______________________

In case of an emergency – Please list a name and phone number of a person to notify if you cannot be reached.

NAME____________________________________________PHONE # ____________________

MEDICAL INFORMATION
   PHYSICIAN_______________________________________ PHONE #____________________

   HEALTH INSURANCE CO. ______________________________________________________
   
   POLICY # _____________________________________________________________________

Is the student subject to any of the following or have any other significant health problems of which the director or chaperones should be
aware?  Circle reply:

Asthma                Diabetes                Seizure Disorders                Heart Disease

High Blood Pressure                Bleeding Disorders                Others_______________________________________

Is the student allergic to any medications, foods, or insect toxins?        Yes                No

If so, please list the specific medication, foods, insects, etc_______________________________________________

_____________________________________________________________________________________________

Please list all medications this student is taking
_____________________________________________________________________________________________

Can this student swim?        Yes        No

Is this student subject to motion sickness during travel?                Yes         No

Since a medical emergency could arise while your child is with the band, please fill out and sign the statement below.  All information on
this form will remain confidential.


To whom it may concern:  In the event of an emergency, I hereby give permission for the medical treatment of my child,
______________________________________________
(band member's name)

Parent/Guardian signature_____________________________________

Notary Signature_____________________________________________Date_________

My commission expires_______________________