Rochester Elementary Band

Medical Authorization
It is absolutely necessary for the band directors to have telephone numbers where the parent, or person designated by the parent, can be
reached in case of an emergency. Although this information is available in the individual school offices, we often meet with music students after
school hours and in centrally located areas where we do not have immediate access to that emergency information. This information will help
us to locate help for your child if it becomes necessary. Incomplete forms will be sent back home to be finished. All items with a star (*) are
required.

This form needs to be filled out completely. *Child’s School: __________________________

*Child’s Name ___________________________________________ *Date of Birth ____/____/____

*Mailing Address __________________________________________________________________

STREET TOWN ZIP CODE

*Email Address ________________________________________@_________________________

It is very important that you print clearly!

*Please indicate below who to call first by number:

*Father/Guardian ____________________________________________________________________________

*Home Phone.# ____ ____ ____ / ____ ____ ____ /____ ____ ____ ____

*Cell Phone# ____ ____ ____ / ____ ____ ____ / ____ ____ ____ ____

*Employed at ___________________________________________*Bus. Phone.#

_________________________

*Mother/Guardian ____________________________________________________________________________

*Home Phone. # ____ ____ ____ / ____ ____ ____ /____ ____ ____ ____

*Cell Phone # ____ ____ ____ / ____ ____ ____ / ____ ____ ____ ____

*Employed at ___________________________________________Bus. Phone.# _________________________

*DESIGNATED PERSON TO CALL IF PARENTS CANNOT BE REACHED:

*Name _______________________________________________*Tel. # _______________________________________

If there is an emergency and I cannot be reached, I authorize any school personnel to secure medical help for my child.
It is my understanding that this authorization will be in effect during the time my child is at an elementary band activity
unless I notify the band directors of its withdrawal.

*Please list any health conditions such as vision or hearing problems, allergies, chronic medical problems, injuries. etc .
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

*Date ______/______/______ *Signed _________________________________________________

Parent/Guardian (required)