2020-21 Medical Consent Form
Thank you for taking the time to fill out this form.   Double check all entries for accuracy because it will affect our ability to communicate information to you in a timely manner. Please use format examples, proper punctuation and correct capitalization.
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First Name *
Last Name *
Date of Birth *
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Age *
Sex *
Address *
City *
State *
Zip Code *
Primary Phone Number- Please use this format (xxx-xxx-xxxx) *
Secondary Phone Number- Please use this format (xxx-xxx-xxxx) *
Primary Emergency Contact Name *
Primary Emergency Contact Phone Number  (xxx-xxx-xxxx) *
Secondary Emergency Contact Name *
Secondary Emergency Contact Phone Number (xxx-xxx-xxxx) *
Name of Insurance Company *
Policy Holder's Name *
Group Number *
Policy Number *
Special Insurance Instructions *
Primary Care Physician's Name *
Primary Care Physician's Phone Number (xxx-xxx-xxxx) *
Please list other physicians' names and phone numbers who should be consulted in the event of emergency or medical problems. *
Dentist's name and phone number (orthodontist, if applicable) *
List all of participants' allergies (drugs, insects, food, etc.) If none, state "none". *
Does participant have any medical or health problems? If none, state "none". *
Indicate date of last tetanus shot *
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Is the participant on any medication? If yes, please list. If none, state "none". *
Are there any activities, such as strenuous activities, to be restricted?  If none, state "none". *
Does participant have any dietary restrictions? If none, state "none". *
I understand that it is my responsibility to provide for the expense of any medical or hospitalization that might be required by this participant.  Trussville City Schools, Hewitt-Trussville High School and the Hewitt-Trussville High School Band are excluded from financial obligations.  I understand that my personal medical and hospitalization insurance available to my family will provide coverage.   I further understand that in the event my child (or participant) requires medical or dental treatment while engaged in the activity of the Hewitt-Trussville High School Band, reasonable effort will be made to contact me; however, if I cannot be reached, I hereby consent and give permission to the Hewitt-Trussville High School band director or any adult chaperone acting on behalf of the Hewitt-Trussville High School Band with respect to the activity, as agent for me, to consent to any x-ray examination, injections, anesthesia, medical, dental or surgical diagnosis and treatment, and hospital care and treatment advised and supervised by a physician, surgeon, dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital.   To the best of my knowledge, I have listed above all of my child's (participant's) medical allergies, medications being taken, medical problems and other pertinent information.  My child (or participant) has permission to participate in all prescribed activities except as noted by me.                   *
By entering your name below, you are stating that you agree to the statement above. *
Date Signed *
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