26_27 Clover Band Permission & Med Forms

Clover School District

Field Trip & Medical Treatment Permission and Release

Full Name

First NameMiddle NameLast NameSuffix

2026-2027 Grade Level

Student's Primary Home Address

Number & Street Name 101 Awesome Lane

Street Address Line 2

CITYState / Province

ZIP

STUDENTS EMAIL ADDRESS

example@example.com (the one you check regularly)

Student's T-Shirt Size

Unisex Adult Sizes

STUDENTS CELL NUMBER

Which Instrument/Caption are you in?

Students Birth Date

Date

#1 Parent/Guardian Name (Student's Primary Residence):

First NameMiddle NameLast Name

#1 Parent/Guardian Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

#1 Parent/Guardian Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

#1 Parent/Guardian Email Address

example@example.com

#2 Parent/Guardian Name:

First NameMiddle NameLast Name

#2 Parent/Guardian Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

#2 Parent/Guardian Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

#2 Parent/Guardian Email Address

example@example.com

EMERGENCY CONTACTS: (In the event we are not able to contact you the parent/guardian(s), please list two alternate contacts that are not listed above)

#1 Name of Alternate Emergency Contact (NOT parent/guardian)

First NameLast Name

Relationship to the student

#1 Phone Number of Alternate Emergency Contact (NOT parent/guardian)

Please enter a valid phone number.Format: (000) 000-0000.

#2 Name of Alternate Emergency Contact (NOT parent/guardian)

First NameLast Name

Relationship to the student

#2 Phone Number of Alternate Emergency Contact (NOT parent/guardian)

Please enter a valid phone number.Format: (000) 000-0000.

IN THE EVENT OF EMERGENCY CONDITIONS, THE FOLLOWING PROCEDURES WILL BE FOLLOWED:

1. EMERGENCY FIRST AID WILL BE GIVEN BY A CHAPERONE OR OTHER QUALIFIED PERSON.

2. IN THE CASE OF SERIOUS INJURY/ILLNESS: THE STUDENT WILL BE TRANSPORTED TO THE NEAREST HOSPITAL.

3. REASONABLE EFFORT WILL BE MADE TO CONTACT PARENT/GUARDIAN REFERENCED ABOVE. IF AM UNABLE TO BE REACHED, I UNDERSTAND AND AGREE THAT MY CHILD WILL BE TAKEN TO A MEDICAL FACILITY FOR EVALUATION AND TREATMENT, IF NECESSARY. I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS THE CLOVER SCHOOL DISTRICT, THE BOARD OF TRUSTEES, EMPLOYEES, AND CHAPERONES FOR ANY INJURY THAT MAY OCCUR TO MY CHILD WHICH IS NOT A RESULT OF ACTION OR INACTION BY THE LISTED REPRESENTATIVES.

INSURANCE PROVIDER/COMPANY NAME

NAME OF SUBSCRIBER/RESPONSIBLE PARTY

POLICY #

PARENT/GUARDIAN SIGNATURE (This must be the INSURANCE SUBSCRIBER)

DATE

Date

To assist the Staff/Chaperones in providing careful supervision of the health and safety of your student, please advise of any conditions needing attention. Please attach any additional needed explanations. ESPECIALLY REGARDING FOOD ALLERGIES!!!

Has your student been diagnosed and/or treated by a Healthcare Provider for ADD/ADHD?

Has your student been diagnosed and/or treated by a Healthcare Provider for asthma or other breathing problems?

Does your student require an oral antihistamine/asthma inhaler?

Has your student been diagnosed and/or treated by a Healthcare Provider for diabetes or hypoglycemia?

Has your student been diagnosed and/or treated by a Healthcare Provider for any Emotional/Behavioral/Psychological condition?

Has your student been diagnosed and/or treated by a Healthcare Provider for frequent headaches or migraines?

Has your student been diagnosed and/or treated by a Healthcare Provider for any Orthopedic Condition?

Have your student been diagnosed and/or treated by a Healthcare Provider for a heart condition?

Have your student been diagnosed and/or treated by a Healthcare Provider for Epilepsy/Seizures?

Has your student been diagnosed and/or treated by a Healthcare Provider for High/Low Blood Pressure?

Has your student been diagnosed and/or treated by a Healthcare Provider for kidney or liver problems?

Has your student been diagnosed and/or treated by a Healthcare Provider for anemia?

Has your student been diagnosed and/or treated by a Healthcare Provider for something not listed? (Please list below)

If your student has been diagnosed and/or treated by a Healthcare Provider for something not listed please list below:

Has your student had a tetanus shot in the last 7 years?

Date

Does your student have ANY FOOD ALLERGIES?

If Yes to the previous question, please specify

Does your student have ANY INSECT ALLERGIES?

If Yes to the previous question, please specify

Does your student have ANY OTHER ALLERGIES?

If Yes to the previous question, please specify

Does your student have a problem with Motion Sickness?

Does your student have ANY SEASONAL ALLERGIES?

If Yes to the previous question, please specify

Does your student have ANY ALLERGIES to MEDICINE?

If Yes to the previous question, please specify

Does your student require emergency epinephrine?

Does your student have a problem with Sleep Walking?

Is your student taking any medications currently? (IF YES, please list ALL medications your student is currently taking below) (This information will be used to collect/compile information needed when our group is traveling, and medicines need to be administered by school level officials in the absence of the parent/guardian) (Over the Counter Meds require a form to be administered by students during school day/trips) (Prescription meds require a separate form for the CSD officials to administer just like nurse meds at CSD schools)

Medication

Reason for Medication

When is it given? (morning/noon/evening? with food/without food?)

Medication

Reason for Medication

When is it given? (morning/noon/evening? with food/without food?)

Medication

Reason for Medication

When is it given? (morning/noon/evening? with food/without food?)

In consideration of permitting my child to accompany the Clover High School Band Program on its trips to football games, festivals and other related band trips during the school year 2026-2027, I hereby agree to indemnify and hold harmless the Clover High School Band, Clover School District #2, its teachers, employees, chaperones and trip sponsors against any claim for damages, compensation or otherwise on the part of said minor(s) or his (her) heirs, executors or administrators and to reimburse or make good any loss or damages or costs the Clover High School Band, Clover School District #2, its teachers, employees, chaperones or trip sponsors may have to pay if litigation arises on behalf of any claims made by said minor(s) or anyone on his (her) behalf as a result of injuries sustained by my child on said trips. The student participant listed above and the parent(s)/guardian(s) whose signature(s) appear below hereby consent to any and all medical and, or surgical procedures, including anesthesia and operations which may be deemed necessary and/or advisable by his/her attending physician and surgeons. I do understand that every effort will be made to contact me prior to such treatment and/or decisions being made. In the event that I cannot be reached prior to treatment, I hereby authorize the Band Staff or Booster Parent Chaperone to secure proper treatment for my child as deemed necessary by a licensed medical professional. The intention hereof, being to grant authority to administer and perform any, and all procedures, which may now, or during a patient's care, be deemed advisable or necessary.

Parent/Guardian Name (printed)

Parent/Guardian Name Signature

Date