PERMISSION AND MEDICAL RELEASE FORM



Student Name_____________________Student Number__________________Grade____


I/WE, the undersigned, hereby grant permission for my/our son/daughter, as a member of the South Plantation Marching Paladin Band, to participate in Band related activities, and to accompany the Band or Units threreof on trips, local and otherwise. By my/our signature, we hereby release and hold harmless South Plantation High School and the individual principal, teachers, parents, and other chaperones, from all liability for mishaps or injuries to the above named student, from starting time of the event until the finish, and from any and all responsibility for the acts of conduct of such student during the activity. I/WE also give permission for a school official or appropriate Band Parent member to request emergency medical treatment, should my/our child become ill or injured while participating in any Band related activity. I/WE further signify that the student listed above is fully insured by the following company:


Name of Company_________________________Type of Policy______________________


Policy Address___________________________Policy Number______________________


Parent/Guardian Signature____________________________________________________


Any medical conditions we should be aware of:_____________________________________


Please List Allergies:________________________________________________________


Home Phone:__________________________Emergency Phone:____________________


Home Address:____________________________________________________________


Emergency Contacts:_______________________________________________________

Name Phone Relationship

Family Physician: Dr.__________________________Phone________________________


Notarization Stamp:

State of Florida, County of Broward
Sworn to and subscribed before this day _____of ____________2004


_______________________________________________________
Notary Public
My Commission expires:

 

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