2021-2022 HTHS Band Medical Consent Form
IMPORTANT!  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.  Please make sure that the primary and secondary contacts are people who can be contacted at any time while you/your child is participating in a band activity.
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Participant's First Name *
Participant's Last Name *
Birth Date *
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Sex *
Grade *
Address *
City *
State *
Zip Code *
Primary Emergency Contact Name *
Primary Emergency Contact Phone (###-###-####) *
Secondary Emergency Contact Name *
Secondary Emergency Contact Phone (###-###-####) *
Does the participant have or ever had any of the following? Check all that apply *
Required
If yes, please describe
Is participant taking any prescription medications? *
If yes, please list (If participant uses an epi-pen please list here)
Participant's Primary Care Physician's Name *
Participant's Primary Care Physician's Phone (###-###-####) *
Please list other physicians' names and phone numbers who should be consulted in the event of emergency or medical problems.
Date of last tetanus shot *
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Name of Insurance Company *
Policy Holder's Name *
Policy Holder's Date of Birth *
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Policy Number *
Group Number *
Special Insurance Instructions
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 insurance available to my family will provide coverage. I further understand that in the event my child (or participant) requires medical 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, Assistant Band Director or Head Chaperone acting on behalf of the Hewitt-Trussville High School Band with respect to the activity, as agent for me, to consent to any emergency medical treatment, and hospital care/treatment advised and supervised by a physician 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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