20-21 CHS Band Travel & Medical Release Form

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Student LAST Name *

Student FIRST Name *

Insurance Company (In case of an accident or injury) *

Policy Number *

“I hereby give my consent for the above named student to go on school sponsored trips with the band, band directors or representatives. I also give my consent for school employees to secure emergency first aid or medical services for the above named student. I release the Burleson Independent School District and all accompanying school authorities and chaperones from all responsibility pertaining to claims and expenses in the case of accident, injury, or loss of life that might occur. I understand that all reasonable precautions will betaken to insure the safety of my child during this activity.” Parent/Guardian Electronic Signature (please type your name below) *

As a parent/guardian of the above named student, I consent to the following: *

My child may swim (if swimming is an option), and I have APPROVED the swimsuit

My child may NOT swim

Required

My child is taking this/these prescription medication(s) *please type name of medication, milligrams per dose, and frequency of dosage.

My child has my permission to KEEP, CARRY, AND TAKE all medications on his/her own

Yes

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My child may take these over the counter medications, if necessary

Food or drugs which the student is known to be sensitive or allergic. (Example: suffa and penicillin)

Any chronic illness such as diabetes, asthma, or epilepsy

List any other information below that you feel WE SHOULD know

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