Westlake Choir - Medical Release Form 2019-2020
Please complete the following information concerning your child's medical history. Students cannot travel on trips until this form is received.
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Student First Name *
Student Last Name *
Student Grade *
Student Date of Birth *
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DD
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Parent/Guardian Name *
Parent/Guardian Cell Phone *
Address *
Name of Family Physician *
Phone Number of Family Physician *
Does your child have medical insurance? *
Family Insurance Company
If no insurance, please leave blank
Policy Number
If no insurance, please leave blank
Date of Last Tetanus Shot *
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DD
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Does your child have any existing medical conditions? *
If yes, please check appropriate items below
Please list any medications your child will take on trips.
For each medication, please include frequency and dosage
Please print your student's name here *
You (Westlake High School Choir directors, chaperones, and designees) are hereby authorized to obtain routine medical or hospital care and emergency medical and surgical hospital care as necessary for my child, the above named student, while traveling with Westlake High School Choir from August 21, 2019 to May 28, 2020. *
Required
Parent/Guardian Digital Signature *
Please print your full name. Your name in this box constitutes a digital signature for permissions granted and other information contained in this form. The date and time of your signature will be logged when you click "Submit".
Choir Handbook Acknowledgment
I acknowledge that I have read the 2019-2020 choir handbook on the school website and agree to the terms outlined therein. *
A copy of the Westlake Choir Handbook is available under the Forms tab on our website year-round. You may also review a copy of the choir handbook here for your convenience: https://docs.wixstatic.com/ugd/ae4775_901ccca56cb24a68b23bc8d20678248f.pdf
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