Parents,

Since Medical Malpractice lawsuits have been on the rise lately, many hospitals and doctors will not treat a child without parents’ consent (unless it’s a matter of life or death). Please fill out and sign this form so that in the event of an emergency, we the staff of BHS Band can do our job of making sure your child receives the best medical attention available. This signed and notarized document must be on file in our Emergency Information File before you child will be allowed to participate in any school sponsored event, field trip, competition, or travel with the BHS Band. All the information contained herein will be held confidential between the band director and parent/guardian and will not be used for any other purpose than emergency medical treatment or conditions.

Members Name:________________________________________________ Male __ Female __

Parents/Guardians Name(s):_____________________________________________________________

Home Address:_________________________________________________ City:____________________

Home Phone: (901) _________- _______________ may this number be submitted to band boosters as a point of contact for important booster information?

Mobile Phone(s): _________________________________________, ____________________________________________

Parent’s Work Phone: _________________________________, _________________________________

Person to contact If Parent/Guardian are unavailable:

Name________________________________ Relationship:___________________ phone:__________________

Name________________________________ Relationship:___________________ phone:__________________

Allergies:_________________________________________________________________________________

Medical Conditions:______________________________________________________________________

Daily Medications:_______________________________________________________________________

Insurance Name:________________________________________

Policy Holder’s Name:____________________________________