You are on page 1of 2

NORTH ATTLEBORO HIGH SCHOOL MUSIC DEPARTMENT

HEALTH INFORMATION FORM and LIABILITY RELEASE


All sections ON BOTH SIDES, MUST be completed and returned by March 6, 2015 to allow time for
processing. If additional space is required for medications or health information, please attach a separate sheet.

I. GENERAL INFORMATION:
Students Name _____________________________________________ Date of Birth_____________
Home Address _____________________________________________________________________
# and street City State Zip
Parent or Guardian __________________________________________________________________
Telephone (home) _____________________ (work) __________________ (cell) _________________
Emergency Contact Name:_____________________________________________________________
Telephone (home) _____________________ (work) __________________ (cell) _________________
Insurance Carrier Name __________________________ Policy Holders Name: ___________________
Insurance Group # and Policy # __________________________________________________________
II PRESENT OR CONTINUING HEALTH PROBLEMS:
The parent or guardian must complete the section below for ALL medications (prescription and
nonprescription, including Tylenol, ibuprofen, Sudafed, etc) routinely taken by your child. All medication, with the
exception of inhalers, EpiPens and other medications or devices used in the event of life threatening
situations, will be held and administered by a designated chaperone. Please send only the amount of
medication required for the duration of the trip, plus one day. All medication should be in the original
prescription bottle, labeled with the students name and specific dosage as prescribed by his/her physician.

Name of Medication Dose Frequency Prescription Instructions:


(Time to be taken, etc.)
YES / NO
YES / NO
YES / NO
YES / NO

I authorize administration of the medication(s) listed above to my child by a designated chaperone:


SIGNATURE-PARENT OR GUARDIAN_____________________________ Date Signed _____________
I give permission for my child to be administered the following as needed for minor discomfort
(check all that apply): __Tylenol __ Advil __ Cough drops __ Nasal Decongestant __ Antacid
__ Dramamine __Imodium __ Pepto Bismol __ Mucinex (Expectorant)
SIGNATURE-PARENT OR GUARDIAN_____________________________ Date Signed _______________

III. PAST HEALTH TREATMENT -Answer YES or NO to the following, and briefly explain all yes answers in space provided. Has the
student been treated for:
Heart condition: YES / NO ________________________________________________________
Allergies: YES / NO ________________________________________________________
Fainting/dizzy spells YES / NO ________________________________________________________
Convulsions YES / NO ________________________________________________________
Diabetes YES / NO ________________________________________________________
Other YES / NO ________________________________________________________
IV. EMERGENCY AND NON-EMERGENCY MEDICAL AUTHORIZATION and LIABILITY RELEASE:
We(I) are the parent(s) or legal guardian(s) of ___________________________ (student) and hereby grant
permission to take him/her to a doctor or hospital should the need arise, and authorize medical treatment,
including but not limited to emergency surgery or medical treatment and assume responsibility of all medical
bills, if any. Further, should it be necessary for him/her to return home due to medical reasons, disciplinary action
or otherwise, we(I) hereby agree to assume all transportation cost.

Parent or Guardian (Print)

Parent or Guardian (Signature)

Date

Furthermore, as parent/guardian of ______________________ (student) I agree to hold harmless and


indemnify the Town of North Attleboro, the North Attleboro School System, their officers, agents and
employees, from any and all liability, loss, damages, costs, or expenses which are sustained, incurred, or
required arising out of the actions of my dependent in the course of the field trip.

Parent or Guardian (Print)

Parent or Guardian (Signature)

Date

OPTIONAL: Please attach a photocopy of your childs Medical Insurance Card.

THIS FORM MUST BE COMPLETED IN FULL WITH


ALL SIGNATURE LINES COMPLETED
FOR YOUR STUDENT TO ATTEND THE TRIP.