Asa Low Panther Band Forms
Field Trip/Medical Release/Handbook Acknowledgement
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Email *
Student name *
Address *
City *
Emergency contact name *
Phone number *
Alternate number
Secondary Emergency contact *
Phone number *
Family Doctor *
Phone *
Student’s Insurance carrier *
Policy Number *
List any allergies the student has (including drug allergies) *
List any medications that are being taken *
List any conditions that may restrict physical activity *
By typing my name below, I do hereby give Troy Bell, Christin McNair, Nathan Wood, or their designee, the authority to seek medical attention for the above named student in the event of an emergency or in any situation that requires medical attention. *
By typing my name below, I hereby certify that my son/daughter has my permission to participate in field trips with the Asa Low Intermediate School Band during the 2022-2023 school year. *
By typing my name below, I agree that I and my son/daughter will abide by the policies found in the Asa Low Panther Band Handbook. A copy of the handbook can be found on the band website at alisband.weebly.com. *
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