Austin-East Band Medical Release/Travel Consent Form 2020-21
All students/families associated with the Austin-East Band will fill out the form in its entirety.
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Student Name *
Address *
Grade *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Medical History - (Current problems, Physical, Limitations, illnesses (verified by physician) *
Allergies Medicine *
Food allergic to: (nuts, bananas, etc...) *
Surgery/Hospitalization *
Medications student is currently taking *
Physicians Name *
Physician's Phone number *
PARENT NAME *
Phone number - Cell *
Home telephone number *
Paernt email *
HEALTH CARE PROVIDER - Name of Insured *
Member number *
Group or Policy# *
Name of Insurance Company *
Address *
Phone *
MEDICATIONS - I grant permission for the following prescription medication to be dispensed to my child by the Austin-East Band Boosters.  - *
Required
I grant permission or the following over-the-counter medications to be dispensed to my child by the Austin-East Band Boosters. *
Required
TRAVEL CONSENT - I hereby give consent my child to represent his/her school in all band activities for the 2020-21 school year.  In case of emergency, I understand that every effort will be made to contact parents/physician.  In the event i cannot be reached, I hereby grant permission to a licensed hospital and/or health center staff members to administer immediate medical treatment as deemed necessary to my child should he/she injured in all functions.  Further, I understand that I am responsible for payment of expenses incurred relating to my child's medical treatment.  PARENT SIGNATURE AND DATE *
IN CASE OF EMERGENCY - Alternate Parent/Guardian Contact *
Relationship *
Home Phone # *
Cell *
Work # *
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