Sherando High School Band 2022-2023           Emergency Contact / Medical Information Form
In the event of an emergency or concern (medical or otherwise), it may be necessary to contact you or a person authorized to act on your behalf.  By signing below, you give the directors, staff, and adult chaperones authority to obtain any medical services deemed immediately necessary by attending physicians and agree to be financially responsible for any expenses incurred.  The directors, staff, and chaperones will use their best judgement and will act in the best interest of the good health of the student and the group.

E-mail *
Student Name: *
Parent/Guardian Name: *
Mailing (Physical) Address: *
Home Phone: *
Work Phone: *
Cell Phone: *
In the event that I cannot be immediately contacted, the following individuals are authorized to act on my behalf:  (Please list the individual's NAME, PHONE, and relationship to student's family) *
Insurance Company (where student is covered): *
Insurance Policy Number (where student is covered): *
Allergies or Conditions of which you would like to make us aware: *
Please list any medications taken: *
If considered necessary by the directors or chaperones during band trips, my child may be given appropriate over-the-counter medications such as pain relievers, antihistamines, decongestants, upset stomach relief, etc. *
My child should NOT be given the following: *
Parent/Guardian - Electronic Signature (please sign with your full name, make sure this matches the email user listed above) *
Date: *
HH
/
NN
/
ÉÉÉÉ
Please use this section to communicate any additional information that you wish for us to have.   Thank you very much for your time, and GO WARRIORS!!
A válaszairól másolatot küldünk a megadott címre.
Küldés
Űrlap tartalmának törlése
Google Űrlapokon soha ne adjon meg jelszavakat.
reCAPTCHA
AdatvédelemFeltételek
Az űrlapot a(z) FCPS Google Workspace for EDU domainen belül hozták létre. Visszaélés jelentése
Google Űrlapok