Register For Bandys Band Boosters

Medical Form

*Emergency Authorization*

By filling out this form and clicking the 'Yes I Confirm" at the bottom of this page:

A. I authorize band instructors and chaperones to administer first aid, seek medical attention from a licensed physician, and arrange transportation to a medical facility if the person named above is seriously ill or injured and requires hospitalization.

B. I authorize the attending physician to provide any treatment deemed necessary for the individual's welfare.

C. I release and discharge the band instructors and volunteer chaperones from all liability in the event of the accident or injury resulting from first aid or transportation to a medical facility. I also release them from any liability for injuries or damages that may occur.

This version maintains all original requirements and authorizations, ensuring clarity and legal protection for the band and families.

First Name

Last Name

Phone Number

Address

State

City

Zip

Group (Circle what applies)

CONCERT BAND

MARCHING/SYMPHONIC BAND

GUARD

CHAPERONE/DRIVER

Date of Birth

Parent/Guardian

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Parent/Guardian Phone

Parent/Guardian 2

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Parent/Guardian Phone 2

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Emergency Contact (Other than parent/guardian)

Character limit (20) reached

Emergency Contact Phone

Medical Conditions/Concerns

Character limit (50) reached

Current Medications and Dosages

Character limit (50) reached

Allergies (food, medications, insects, etc.)

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Date of Last Tetanus Shot:

Family Physician

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Family Physician City

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Family Physician Phone

Character limit (10) reached

Specialty Physician (if applicable)

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Does the student have school insurance?

If no school insurance, another form of medical insurance is required to participate in band activities. Please provide details below and provide a photocopy of your insurance card. Name of Insurance Company:

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Name of Insured:

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Insurance Policy Number:

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Insurance Group Number:

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I agree with the above statements and authorize as stated above.

Yes

Electronic Signature by Parent/Guardian

Character limit (50) reached

Medical Form Signature Date

Register For Bandys Band Boosters

Medical Form

By filling out this form and clicking the 'Yes I Confirm" at the bottom of this page:

A. I authorize band instructors and chaperones to administer first aid, seek medical attention from a licensed physician, and arrange transportation to a medical facility if the person named above is seriously ill or injured and requires hospitalization.

B. I authorize the attending physician to provide any treatment deemed necessary for the individual's welfare.

C. I release and discharge the band instructors and volunteer chaperones from all liability in the event of the accident or injury resulting from first aid or transportation to a medical facility. I also release them from any liability for injuries or damages that may occur.

This version maintains all original requirements and authorizations, ensuring clarity and legal protection for the band and families.

Preview not Available