SPRING HILL

SPRING HILL HIGH SCHOOL BAND

MEDICAL RELEASE & PERMISSION FORM

3101 SPRING HILL RD., LONGVIEW, TX 75605  PHONE:  903-759-4404

(For the 2010-2011 School Year)

NAME OF STUDENT (PLEASE PRINT) _____________________________________________________________________________

DATE OF BIRTH _______/_______/__________

ADDRESS ____________________________________________________________________________________________________

CITY ________________________ STATE __________ ZIP_______________ PHONE ______________________________________

NAME OF PARENT/GUARDIAN ______________________________________ DAYTIME PHONE ______________________________

MEDICAL INSURANCE CO. _________________________________ POLICY # _________________ GROUP _____________________

MEDICAID OR MEDICARE ________________________________________ ID # ____________________________________________

LIST ANY MEDICAL CONDITIONS OR ILLNESS ________________________________________________________________________

_______________________________________________________________________________________________________________

LIST ANY MEDICATIONS TAKEN (GIVE COMPLETE INSTRUCTIONS) ______________________________________________________

_______________________________________________________________________________________________________________

LIST ANY ALLERGIES (INCLUDING MEDICATIONS) ____________________________________________________________________

PERSON(S) TO CONTACT IN CASE OF EMERGENCY:

NAME ______________________________________________________ PHONE ____________________________________________

ADDRESS ______________________________________________________________________________________________________

NAME ______________________________________________________ PHONE ____________________________________________

ADDRESS ______________________________________________________________________________________________________

I GIVE MY PERMISSION FOR MY CHILD

__________________________________________, TO PARTICIPATE IN ALL ON OR OFF CAMPUS SCHOOL-RELATED ACTIVITIES AND/OR TRIPS.

I, who by law may do so, authorize, pursuant to Section 35.01 of the Texas family code, the adminstration of emergency medical treatment to he/she who is subject of this form.  I understand all reasonable safety precautions will be taken at all times.  I do hereby request, authorize and consent to such care and treatment as may be given to said student by any physician, trainer, nurse, hospital, or school representative, and I do hereby agree to idemnify and save harmless the school and any school representative from any claim by any person whomsoever on account of such care and treatment of said student.  I understand that in the event medical intervention is needed, every attempt will be made to contact the person(s) listed above immediately.

NOTE:  FOR ALL ATHLETES COVERED UNDER THE UIL ATHLETIC INSURANCE POLICY I understand that the SHISD student athletic insurance is considered to be a secondary policy which may not cover 100% of medical expenses, and I agree to assume full responsibility for payment of any medical expenses incurred on behalf of my child/dependent.  A complete list of physicians and hospitals will be provided in the office.  Please contact the high school for further information before treatment.

_______________________________________________________________  ________________________________

SIGNATURE OF PARENT/GUARDIAN                                                       DATE

THIS FORM MUST BE RETURNED BEFORE PARTICIPATING IN ANY SCHOOL-RELATED ACTIVITIES ON OR OFF CAMPUS.