West Briar Middle School Orchestra
Medical Release Form
2009-2010

Please fill out form completely.  If a blank does not apply, please write N/A.

Student’s Name ___________________    ___________________
                              
Parent/Guardian _________________________________
Address: _________________________________________________________________________

Phone #s: Home_____________ Mobile ______________
Work _____________ Other _______________

Student’s Age _____ Grade ______  

Allergies or existing Medical Problems: (Please describe in full.  Use another sheet if necessary.) ___________________________________________________________________________ ___________________________________________________________________________

Current medications: _____________________________________
Family Physician: ___________________ Phone: ______________

Insurance Company: _____________________________________
Policy Number: _________________________________________

Relative/Emergency Contact: Name: ________________________
Phone: ________________________

In case of medical emergency, I, _____________, hereby give permission for a qualified, licensed physician to treat my son/daughter, ____________________.  This form is used for the entire school year’s orchestra trips and activities.

Signed ____________________ Date: _______________
Parent/Guardian