2024_Medical Form / Permission to Travel

School District of Pickens County 1348 Griffin Mill Road

Permission to Participate & Travel

School: Easley High School Address: 154 Green Wave Boulevard Easley, SC 29642

Event: All Band Activities for the 2024-25 school year

Dates: July 2024-May 2025

Student's Last Name

Student's First Name

Student's Middle Name

Parent/Guardian completing form FIRST name.

Parent/Guardian completing form LAST name.

I __________________(parent/guardian), herby give permission for EHS Band Program to utilize photos and videos that include, (but not limited to), of performances, rehearsals, and other band activities during the 2024-2025 year. These will be used for recruitment, retention, and public relations. (IF you want to OPT OUT Please Contact the Director)

Signature of Parent/Guardian

Date

Yes, as parents/guardians of the above named student, permission is granted to participate in this event/events. It is understood that every effort will be made by the school/sponsor to ensure qualified drivers, adequate numbers of chaperones, and constant supervision is provided during this event/events. The school personnel will do everything in their power to provide for the safety of each child. ANY medical/physical conditions?

ANY medical/physical conditions?

Signed

Date

Parent/Guardian (completing form) Cell Phone

Parent/Guardian (completing form) Work Phone

Parent/Guardian (completing form) Home Phone

No, the above named student may not participate in this event/events.

Signed

Easley High School Bands and Ensembles Student - Family - Medical Information

This form will be used for all events sponsored by Easley High School Bands and Insembles if any of the information changes, please contact the school office 864-397-3196

Student Last Name

Student First Name

Student Middle Name

Student Preferred Name

Student Date of Birth

Date

Student Grade Level for 2024-25 Year

T Shirt Size

Student Cell Phone

Student Email Address

example@example.com

Parent/Guardian #1 - Full Name

First NameLast Name

Parent/Guardian #1 - Relationship to Student

Parent/Guardian #1 - Address (Include street name, city, state, zip code)

Parent/Guardian #1 - Home Phone

Please enter a valid phone number.

Parent/Guardian #1 - Employer

Parent/Guardian #1 - Work Phone

Please enter a valid phone number.

Parent/Guardian #1 - Cell Phone

Please enter a valid phone number.

Parent/Guardian #1 - Email

example@example.com

Parent/Guardian #2 Full Name

First NameLast Name

Parent/Guardian #2 - Relationship to Student

Parent/Guardian #2 - Address (include street name, city, state, zip code)

Parent/Guardian #2 - Home Phone

Please enter a valid phone number.

Parent/Guardian #2 - Employer

Parent/Guardian #2 - Work Phone

Please enter a valid phone number.

Parent/Guardian #2 - Cell Phone

Please enter a valid phone number.

Parent/Guardian #2 - Email

example@example.com

Student Lives with:

Emergency Contact #1 - Full Name

First NameLast Name

Emergency Contact #1 - Relationship to Student

Emergency Contact #1 - Home Phone

Please enter a valid phone number.

Emergency Contact #1 - Work Phone

Please enter a valid phone number.

Emergency Contact #1 - Cell Phone

Please enter a valid phone number.

Emergency Contact #2 - Full Name

First NameLast Name

Emergency Contact #2 - Relationship to student

Emergency Contact #2 - Home Phone

Please enter a valid phone number.

Emergency Contact #2 - Work Phone

Please enter a valid phone number.

Emergency Contact #2 - Cell Phone

Please enter a valid phone number.

Insurance Carrier

Insurance Carrier Phone

Insurance Policy Number

Family Physician

Physician Phone

Known Allergies

Previous Medical Information

Current Medications

Current Medications (include inhalers): Any medically relevant limitations of the student: Incase of a medicol emergency, it is understood that every parent/guardian cannot be reached, , hereby give permission to the physicion or hospital selected by the group leader, or another adult authorized by themto hospitalize, secure proper treatment for and order injections, anesthesia, or surgery for the above listed minor.

Any medically relevant limitations of the student:

Parent/Guardian Signature

Date

Easley High School Bands and Ensembles Handbook