2026-2027 Medical Information & Medication Authorization

2026-2027 Medical Information & Medication Authorization

Please fill out one form per student participating in the program.
First Name
Last Name
Student ID Number
Grade
Participation
Section
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Student Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information

Please fill out the contact information below. As a band booster, you will be receiving reminders of coming events and other important information.
Parent/Guardian 1

First NameLast Name
Phone - Parent/Guardian 1
Please enter a valid phone number.Format: (000) 000-0000.
Email - Parent/Guardian 1
example@example.com
Parent/Guardian 2

First NameLast Name
Phone - Parent/Guardian 2
Please enter a valid phone number.Format: (000) 000-0000.
Email - Parent/Guardian 2
example@example.com
Medical Information
Special Instructions?
If Yes, Please Describe
Medical Insurance Carrier
If none, put N/A
Medical Group Number
If none, put N/A
Physicians Name
If none, put N/A
Phsician Telephone
If none, put N/A
Dental Insurance Carrier
If none, put N/A
Dental Group Number
If none, put N/A
Dentist Name
If none, put N/A
Dentist Telephone
If none, put N/A
Emergency Contacts
In the event the parent/guardian cannot be contacted we may contact the following:
Emergency Contact 1 Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorization to Administer Medication
Occasionally students may ask the Head Chaperone of the James Logan Band and Color Guard for over-the-counter medication for minor aches and pains. In order to dispense this medication to the student the parent/guardian must give authorization to do so.
I hereby
the Head Chaperone of the James Logan Band and Color Guard to give my child the following over-the-counter medications for headaches, cold and general aches and pains. Generic brands may be substituted.
Check Any or All
Prescription Medcations
Indicate if your child takes any prescribed medication.
Medication
Allergies
Indicate if your child has any allergies.
If Yes, indicate what your child is allergic to and the severity of the allergic reaction.
Diet
Please check any that apply.

Notify us immediately should your students dietary needs change. Failure to do so will result in limited meal options.
My child is:
Please provide information about your child's food allergy.
Please provide information about your child's restricted diet.
Authorization
I give permission for the above named student to receive any necessary emergency medical treatment while traveling or participating with the James Logan Band and Color Guard. To the best of my knowledge, my child has no medical problems that would prohibit my child from participating fully in strenuous physical activity. I agree to assume all financial responsibility for any costs incurred.

As stated in California Education Code § 35330(d), “All persons making the field trip or excursion shall be deemed to have waived all claims against the [New Haven Unified School] District ... or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion.” In the event of illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services. I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any violation of these rules and regulations may result in that individual being sent home at the expense of his/her parent/guardian.

I agree to assume the liability for all occurrences that may occur during authorized band events, performances, and trips, thereby releasing the band directors, chaperones, booster organization, and school from liability during said events, performances, and trips.
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Should be Empty:

2026-2027 Medical Information & Medication Authorization

Parent/Guardian Information

Medical Information

Emergency Contacts

Authorization to Administer Medication

Prescription Medcations

Allergies

Diet

Authorization