PHS BAND MEDICAL HISTORY and BLANKET PERMISSION AND RELEASE FORM 2021

Form IFCB-5
MEDICAL HISTORY PERMISSION AND RELEASE FORM
Student Name

First Name Last Name
Student Age
Full Address
In case of emergency, notify:

First Name Last Name
Emergency Contact Phone Number

Area Code Phone Number
Family Physician
Family Physician Phone Number

Area Code Phone Number
Family Insurance Company:
Insurance Co. Full Address
Immunizations?
Other Medical Issues? Please describe:
PAST MEDICAL HISTORY
Please check all that apply:

Asthma Dizziness Sinusitis Stomach Upset Bronchitis Hay Fever Kidney Heart Diabetes
Food allergies? (Yes/No) blanks . Please indicate what foods? blank .
Insect bites/stings? (Yes/No)
Penicillin or other drug? Please list other drug name (allergy) or indicate N/A
Poison Sumac, Oak or Ivy? Please indicate Yes or N/A
Other allergy? Please describe or indicate N/A:
Previous operations or serious illnesses? Please describe or indicate N/A
Please list current medications (or N/A):
Childhood Diseases:

Chicken Pox Measles Mumps Whooping Cough
Any medical needs which your child has, of which adult supervisors should be aware? Please describe or indicate N/A:
PERMISSION FOR TREATMENT
My permission is granted for school supervisors to obtain necessary medical attention in case of sickness or injury of my student. I agree to release, indemnify, and hold harmless or reimburse the Cobb County School District (District), its Board of Education, and its members, employees, agents, representatives, successors or assignees, as well as its approvedadult trip supervisors (“District Indemnitees”) from and forever promise not to sue them on any and all claims, demands, rights, causes of action, liabilities, losses, damages, costs and expenses (including reasonable attorneys’ fees), whether known or unknown, that I, any other parent or guardian of the abovnamed student, the student or any other successor or assignee may have or may allege to have against the District Indemnitees or which may be brought against the District Indemnitees arising out of or in any manner relating to the student’s participationin the field trips, including but not limited any losses, damages or injuries or to the rendering of emergency medical procedures or treatment.

7/1/14: School Health Services
E-Signature of Parent/Guardian
Date

Month Day Year
Date
Form IFCB-3
"BLANKET" PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL-SPONSORED FIELD TRIPS
Student Information
Student Name:
Date of Birth:

Month Day Year
Date
Address:
Home Phone:
In case of emergency, notify:
Family Insurance Information
Company Providing Insurance:
Policy Number:
Name of Insured:
Group Number:
Medical Information
Family Physician:
Phone:
Phone:
Immunizations:
Does the student need to take medication?
No If so, what medication?

Yes No
If so, what medication?
Special medical conditions:
Previous operations or serious illnesses:
Allergies?

Yes No If yes, please identify allergy: Medication Food Stinging Insects No
No If yes, please identify allergy:
Dietary Restrictions:
Please identify:
Release
Student Name

First Name Last Name
- I hereby request that (Student’s Name -PRINTED ABOVE ): participate in athletic team, band, orchestra, chorus, and/or any series of field trips related to one particular area of study or activity. I understand that transportation may or may not be provided by the Cobb County School District (District In the e vent transportation is not provided by the District, transportation will be the student’s responsibility.
- Detailed trip information, including destination, date, time of departure, time of return, purpose, and supervision, should b e given in writing to the parents at least two (2) weeks prior to each trip in the series.
- The Dist rict does have an indemnity plan pursuant to O.C.G.A. § 20 - 2 - 1090 that may or may not apply relative to the trip. Even if the plan covers some or all of the trip, the coverage amounts may not cover all injuries. I understand that as a parent I have the o ption of, and am encouraged to, purchase student insurance coverage either through the student accident insurance offered by the District or through my own insurance carrier.
- If any emergency medical procedures or treatment are required during the trip, I consent to the trip supervisor(s) taking, arranging for or consenting to the procedures or treatment in his/her or their discretion.
- I agree to release, indemnify, and hold harmless or reimburse the Cobb County School District (District), its Boar d of Education, and its members, employees, agents, representatives, successors or assignees, as well as its approved adult trip supervisors (“District Indemnitees”) from and forever promise not to sue them on any and all claims, demands, rights, causes o f action, liabilities, losses, damages, costs and expenses (including reasonable attorneys’ fees), whether known or unknown, that I, an y other parent or guardian of the above - named student, the student or any other successor or assignee may have or may all ege to have against the District Indemnitees or which may be brought against the District Indemnitees arising out of or in any manne r relating to the student’s participation in the field trips, including but not limited any losses, damages or injuries or t o the rendering of emergency medical procedures or treatment. NOTE: This form must be signed by student if the student is 18 years of age or older.
Name of Parent/Guardian (PLEASE PRINT)
Signature of Parent/Guardian

Clear
Date

Month Day Year
Date
IFCB-3
Should be Empty:

Form IFCB-5

MEDICAL HISTORY PERMISSION AND RELEASE FORM

PAST MEDICAL HISTORY

PERMISSION FOR TREATMENT

Form IFCB-3

"BLANKET" PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL-SPONSORED FIELD TRIPS

Student Information

Family Insurance Information

Medical Information

Phone:

Release

IFCB-3