Leigh PAPA Medical Consent Music, Choral, and Marching Arts.

Leigh PAPA Medical Consent Music, Choral, and Marching Arts.
Select School Year
Complete Date

MonthDayYear
Date
Activity (select all expected)

Marching Band and Color GuardWind EnsembleWinter GuardWinter PercussionJazz BandSymphonic/Concert/Choir
Student Name*

First NameMiddle NameLast Name
Guardian Info:
Guardian1 Name*

First NameLast Name
Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian1 Employer
Guardian1 Phone*

Area CodePhone Number
Guardian1 Alt Phone

Area CodePhone Number
Guardian1 Email*
example@example.com
Guardian2 Name

First NameLast Name
Guardian2 Employer
Guardian2 Phone

Area CodePhone Number
Guardian2 Alt Phone

Area CodePhone Number
Guardian2 Email
example@example.com
Emergency Contact Info:

Must be different than Guardian 1 and Guardian 2 above
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Emergency Contact Relationship*
Enter relationship
PARENT CONSENT:

I am aware of my child’s participation in the {selectSchool} LHS MUSIC DEPARTMENT AND ALL LHS MARCHING ARTS PROGRAMS sponsored by LEIGH HIGH SCHOOL PERFORMING ARTS. I am aware that taking part in this activity carries the risk of injury to my child, particularly due to travel, practice and performance. The directors, instructors, sponsors, and medical parents/chaperones have my permission, for either doctor's orders or an emergency situation when I cannot be contacted, to seek medical assistance at a medical clinic or hospital emergency room at my expense. I certify that I have adequate insurance coverage and I accept full responsibility for any medical expenses arising due to the injury or illness of my child while participating as a member of the organization.
Guardian Signature*

Clear
Special Medical Needs:
Special Needs:
SPECIAL MEDICAL NEEDS, HEALTH PROBLEMS, PHYSICAL RESTRICTIONS (IF NONE, WRITE NONE).
ALLERGIES TO FOOD, MEDICINE, INSECT STINGS, ETC (IF NONE, CHECK "No Allergies").
Allergy Info*

No AllergiesDairy-FreeGluten-FreeVeganVegetarianKosherNut-FreeSeafood AllergyBees/Wasps
Other Allergies:
Additional Medical Info
IF YOUR CHILD REQUIRES SELF-CARRY & SELF-ADMINISTER PRESCRIPTIONS (LIKE AN INHALER, INSULIN, OR AN EPIPEN) PLEASE HAVE THEM CARRY IT AT ALL TIMES, BE SURE TO NOTE IT BELOW, AND INFORM THE SCHOOL. IF YOUR CHILD'S SELF-CARRY MEDICATION IS NOT LISTED BELOW, THEN CHECK "OTHER" AND INPUT MEDICATION IN MEDS RX AREA BELOW.
Self-Carry Medications

EpipenAsthma InhalerInsulinBenadrylOther
PLEASE LIST ALL CURRENT MEDICATION(S) BEING TAKEN
Meds Rx Info
Note: Students taking medications on a regular basis are required to turn these medications to be held in a secure location on any extended trip. A complete list of the student's medications and when they are to be taken must be included. Medications must be in the original prescription container. Students will be able to take their medications as needed.
Meds Info Acknowledgement*

Yes, I Understand
AUTHORIZATION TO TREAT A MINOR:
I (we), the undersigned parent/guardian of {studentName} , a minor, do hereby authorize and consent to any medical treatment rendered under the general or special supervision of any member of the medical profession and emergency room staff. I give my permission to directors, instructors, sponsors, medical parents, and /or chaperones to administer over the counter medication and first aid per doctor's orders or as situationally neccessary. I have indicated below what medications can be given to my child. Those administering the treatment will follow the directions on the medication unless otherwise noted in the child’s medical form.

Please check the box(es) next to what your child can be given as necessary or in an emergency. By default, none will be given. (Emergencies will be determined by the director/instructor/sponsor/medical parents/chaperone.) Medications listed could be a variation of the specific brand name or a generic brand.
Over-the-Counter Medications

TylenolAdvilAspirinAleveIbuprofenPepto-BismolTumsImodiumDrama-mineMidolSudafedCough DropsBenadrylBug SpraySun screen
Other non-prescription meds
Other medication restrictions
I understand that if there are any changes to my student's medical care or needs I will complete a new medical form for Marching Arts.*

Acknowledge
Treatment Signature*

Clear
Should be Empty: