Decatur Show Choir Complex Student Medical Release Form

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Student’s Full Name *

Student’s DOB MM/DD/YYYY *

Parent/Guardian’s Full Name *

Parent/Guardian’s Phone *

Emergency Contact (other than parent/guardian) NAME & PHONE *

Please list any allergies, chronic illness, current illness, past injuries, and past hospitalizations. *

Please list any current medications. *

Physician’s name & number? *

Insurance Company & Policy Number *

Date of last tetanus *

I, the Parent/Guardian of the minor listed above, give ERIK TAYLOR OR SARA PATTERSON authorization to give consent to hospital emergency care and/or medical care or treatment of the above named minor for any illness or injury incurred while I am away or otherwise unable to give such consent. I understand and agree that I am responsible for any and all costs and expenses for emergency and/or medical care or treatment rendered to the above named minor, and that I will be billed for these services. I may then, if I wish, submit music claim for benefits under my insurance carrier. *

I have read and agree with the above statement. I also agree that my acceptance of this electronic form serves as legal consent. Furthermore, I agree that I am the legal parent/guardian of the minor mentioned above or a legal adult 18 years of age.

I disagree with the above statement

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