NORTH FARMINGTON HIGH SCHOOL MEDICAL INFORMATION AND RELEASE FORM
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Email *
Last Name *
First Name *
Middle Initial
Home Phone *
Cell Phone
Address *
City *
Zip Code *
Student Age *
Student Height *
please include feet and inches
Weight (pounds) *
Medical Insurance *
Insurance Company
Policy Number
LIST ANY HEALTH, BEHAVIORAL, OR EMOTIONAL PROBLEMS THE STUDENT HAS, INCLUDING CURRENT INFECTIOUS DISEASE AND ALLERGIES:
LIST CURRENT MEDICATIONS AND/OR TREATMENTS:
ARE THIS STUDENT’S IMMUNIZATIONS CURRENT? *
LIMITATIONS OF ACTIVITIES:
Family Physician (name) *
Family Physician phone number: *
Authorization for treatment
We hereby give permission to the medical personnel selected by the camp/band director to order any routine
and emergency medical treatment; to release any records necessary for insurance purposes; and to
provide or arrange necessary transportation for my child while participating with the North Farmington
High School Band. It is further warranted that if this agreement is signed by one of two parents or
guardians, it is with the authority of the other. This health history is complete as far as I know, and the
person herein described has permission to engage in all camp/band activities except as noted.

Parent/Guardian Signature *
Parent/Guardian Cell Phone *
Date *
MM
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DD
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YYYY
Parent/Guardian Signature
Parent/Guardian Cell Phone
Date
MM
/
DD
/
YYYY
IF IN AN EMERGENCY WE CANNOT BE REACHED, CONTACT:
Emergency Contact Name: *
Emergency Contact Relationship: *
Emergency Contact Phone: *
A copy of your responses will be emailed to the address you provided.
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