FORT WALTON BEACH HIGH SCHOOL BAND

MEDICAL PERMISSION FORM

This authorization for traveling with the FWBHS Band is good for a period of one (1) year from the date of signing.

Last name:	First Name:	Date of Birth:
Address:		Phone:
Name of Parent/Guardian:		Parent/Guardian Phone:
Emergency Contact:		Emergency Phone:
Name of Family Physician
Type of Medial Insurance: Include Policy Number
List all known food, drug, and insect Allergies:
List any pertinent Medical Problems: Include Asthma, joint or muscle injuries, seizure disorders, etc.
List all medications routinely taken: Include dose and frequency. On Band trips, medications will be held by the Band Nurse and administered as directed. All medications must be sent in their original container and be clearly labeled.

Students may not carry any type of personal medications. The Band Nurse will have over-the-counter medications available to treat headaches, muscle pains, cold, cough and stomach upset. Do you give your permission for the Band Nurse to administer medications to your child when needed?

YES NO COMMENTS/EXCEPTIONS: