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Microsoft word - medical_form_2009.doc

MEDICAL INFORMATION, PERMISSION AND RELEASE FORM Health Problems we should know about:(Allergic to Bee Stings, Asthma, Diabetes, Recent Illnesses or Injuries [anything you
have seen a doctor for in the past 6 months], etc.):
Daily/Regular or “as needed” Medications (ex: Allergy, acne medication, etc.):
A WBOP chaperone will have the following over-the-counter medications available to treat common conditions:
Tylenol or Advil (pain/headaches)
Midol (females only - cramps)
Benadryl (allergies)
Sudafed (congestion)
Dramamine (motion sickness)
Tums or Pepto-Bismol (upset stomach)
Imodium (diarrhea)
My student may be given these medications if needed: ____ yes ____ no

All information will be held in the strictest confidence and will be used on an “as needed” basis only.
*** PLEASE FILL OUT BOTH SIDES OF THIS FORM AND ATTACH COPY OF INSURANCE CARD ***
Medical History Permission and Release Form
Name:________________________________________________ Age:_____________________ Address:______________________________________________ Zip:______________________ Incase of an emergency, notify:_____________________________Phone:___________________ Family Physician: ________________________________________ Phone:__________________ Family Insurance Co._____________________________________ Policy #__________________ Insurance Co Address: _____________________________________________________________ Other:___________________________________________________________________________ Asthma___ Sinusitis___ Bronchitis___ Kidney___ Food____________________________ Insect bites/strings____________________ Penicillin or other drug (name)____________________________________________ Poison Sumac, Oak or Ivy_______________________________________________ Other________________________________________________________________ Previous operations or serious illnesses__________________________________________________ medications______________________________________________________________ Special diet (name)__________________________________________________________________ Chickenpox_____Measles_____Mumps____Whooping Cough_____ Any medical needs which your child has, of which adult supervisors should be aware: ___________________________________________________________________________________ My permission is granted for school supervisors to obtain necessary medical attention in case of sickness or injury of my student. I release and waive, and further agree to indemnify, hold harmless or reimburse the Cobb County School District, the Board of Education, its successors and assigns, its members, agents, employees, and representative thereof, as well as trip supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation my have or claim to have, known or unknown, directly or indirectly, from any losses, damages or injuries arising out of, during or in connection with the student's participation in the trip or the rendering of emergency medical procedures or treatment, if any. DATED this__________of___________, 20____ _______________________________________________ NOTARY _______________________

Source: http://www.waltonband.org/docs/ReleaseForms/2009MedicalForm.pdf

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