Apalachee Marching Band
List known allergies: List other medical conditions with details: List all medication student is taking: INSURANCE INFORMATION
Please indicate primary insurance company name: MEDICATION INFORMATION
Please circle all medication that you DO NOT want
Apalachee Marching Band to give your child: IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address): Apalachee Marching Band
Student Name__________________________________________________ Statements
I hereby give my consent for my son/daughter to travel and participate in the Barrow County School Board approved functions/trips with the Apalachee High School Band during the school year listed at the top of this form. The Barrow County Board of Education, its members, employees and agents assume no responsibility for personal injuries and/or property damage which might be suffered by your child, his/her property, or the person or property of others during said function/trip. We hereby expressly release said Board of Education, its members, employees and agents from any and all liability relating to any such injuries or damages. The Barrow County Board of Education’s policies on Student Conduct and Discipline shall be in full force and effect as to all student participants in this function/trip at all times during the same, and any violation of any rule[s] contained therein by our child may result in appropriate disciplinary measures, including suspension and expulsion as provided in said The Barrow County Board of Education, its members, employees and agents are not responsible for any expenses related to this school function/trip except as otherwise The Barrow County Board of Education may require as a condition to our child’s participation in this school function/trip that satisfactory evidence be submitted indicating that our child has sufficient medical insurance in effect during the period of said function/trip. The information provided on the Medical Form is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Apalachee Marching Band or medical form on insurance company to release any information required to process my claims. I authorize reverse) Apalachee Marching Band to obtain necessary medical care for my child. I understand that Marching Band is voluntary and subject to the policies in the Band Handbook. This book is located on the web at apalacheeband.org. I am responsible for knowing the content of this handbook. I understand that I must attend all practices, pre-school camps, football games and marching festivals. That I must be enrolled in band class for the entire academic year. That I must follow all policies in the band handbook. Failure to meet these requirements can result in being removed from the marching band. I understand in order for my student to participate in marching band I must have paid all outstanding debts to the Band Boosters. I must make all payments in accordance with the plan I have selected. Failure to meet these obligations will result in my student being removed from the marching band and other sanctions as approved by the AHS Signatures
I have read and understand the above statements concerning policies pertaining to participation in Marching

Source: http://www.apalacheeband.org/Handouts/Consent%20Medical%20Form%202013.pdf


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