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Medical Band Form 2024
PIEDMONT HIGH SCHOOL
THE PRIDE OF PIEDMONT
Emergency Release Form
2024 Marching Season
I (parent/guardian) give my permission to the Band Directors of Piedmont High School to act as a guardian in the event of an accident involving my child until I am able to be contacted. Also, in the event of an emergency, he/she has my permission of consent to the attending physician/emergency response team to administer any medications or perform any treatments that he/she deems necessary for the proper care and well-being of my child until I am able to be contacted.
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* Indicates required question
Email
*
Your email
Student FIRST Name
*
Your answer
Student LAST Name
*
Your answer
Mother/Guardian Full Name
*
Type N/A if does not apply to you.
Your answer
Mom's Cell Phone
xxx-xxx-xxxx (please use dashes)
Your answer
Mom's Work Phone
xxx-xxx-xxxx (please use dashes)
Your answer
Father/Guardian Full Name
*
Type N/A if does not apply to you.
Your answer
Dad's Cell Phone
xxx-xxx-xxxx (please use dashes)
Your answer
Dad's Work Phone
xxx-xxx-xxxx (please use dashes)
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone
*
xxx-xxx-xxxx (please use dashes)
Your answer
List any medical alerts such as allergies, medicines, or any other medical concerns.
*
Type N/A if does not apply to you.
Your answer
Parent/Guardian Signature
*
By providing your electronic signature below, you agree that this can be used in the same manner as a physical signature.
Your answer
Today's Date
*
MM
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DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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