EMERGENCY RELEASE / EMERGENCY CONTACT / MEDICAL INFORMATION FOR A CHILD

ALTERNATE EMERGENCY CONTACTS

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Student Name

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Parent/Guardian Name Relationship

Home ( ) ________________________________

Cell ( ) ________________________________

Work ( ) ________________________________

___________________ Male _____ Female ______

Date of Birth

____________________________________________

Parent/Guardian Name Relationship

Home ( ) __________________________________

Cell ( ) __________________________________

Work ( ) __________________________________

STUDENT LAST NAME _______________________________

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Emergency Contact Name Relationship

Home ( ) ________________________________

Cell ( ) ________________________________

Work ( ) ________________________________

MEDICAL INFORMATION

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HOSPITAL / CLINIC PREFERENCE

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PHYSICIAN’S NAME PHONE NUMBER

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INSURANCE COMPANY PHONE NUMBER

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POLICY NUMBER / GROUP NUMBER

I hereby grant the Fallbrook Union High School parent volunteers, staff, physician, or other medical

personnel, or any person connected to the school, to determine if emergency care is needed for my child

while participating in band, color guard, or other related activities. I further understand that every reasonable

effort will be made to contact the legal guardians, or emergency contact listed on this release, prior to and

treatment is given.

I give permission for my child to attend field trips. I release Fallbrook Union High School and individuals

from liability in case of accident during activities related to the Instrumental Music Program, as long as

normal safety procedures have been taken.

______________________________________ _____________________________________ Parent’s / Guardian’s Signature Date

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Emergency Contact Name Relationship

Home ( ) ________________________________

Cell ( ) ________________________________

Work ( ) ________________________________

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MEDICATIONS

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KNOWN ALLERGIES OR MEDICAL CONDITIONS WHICH WOULD LIMIT PARTICIPATION