Band Tour Medical Form

Ensemble *

Wind Symphony Symphonic Band

Date of Birth (MM/DD/YYYY) *

Parent/Guardian Information

Primary Parent/Guardian *

First

Last

Primary Parent/Guardian Phone Number *

Secondary Parent/Guardian *

First

Last

Secondary Parent/Guardian Phone Number *

By submit ion of this form I give permission to the physician or hospital to secure proper treatment for and to order medications, injections, anesthesia, or surgery for the student as named above. If an emergency arises, I understand it might be necessary for my son/daughter to receive medical care before I can be contacted.

Band Tour 2015 Medical Form

Student Information

Parent/Guardian Information