Caravel Academy Music Department Medical Authorization Form (Delaware State Choral Festival)

Caravel Academy Music Department Permission Slip & Medical Authorization Form

Delaware State Choral Festival (Glee Club)
Date: Friday April 5, 2019

Time: 8:30am-2:45pm

Cost: $$ for lunch at Chick-fil-a

Other needs: Students should bring bottled water and a bagged snack as we will be eating lunch later than normal

Dress: Jeans and our newest Caravel Music T-Shirt (students attending this years Music in the Parks competition will be receiving this shirt for this competition as well).
Full Name (Participant)*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
As a parent(s)/guardian(s) of the above named student, permission is granted for the above mentioned student to attend the Music Department Trip to The Delaware State Choral Festival on Friday, April 5, 2019 .*

YesNo
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
(3) Emergency Contact/s

If group chaperones/organizers are unable to contact you or any of the people listed as emergency contacts, they make whatever arrangements are necessary in an emergency at no expense to the organization.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
(4) Allergies/Sensitivity- The student is known to react unfavorably or is allergic to the following food/drugs:*
Dietary Restrictions (N/A if not applicable)*
(5) Medical Conditions/Or any other medical concerns (N/A if not applicable)*
(7) Medications:

Please state the name of any prescription medication/s that the student will bring on the trip and the reason for the prescription
Will your child require prescription medication on this trip?*

YesNo
Prescription #1*
Dose*
Time*
Reason*
Prescription #2
Dose
Time
Reason
Prescription #3
Dose
Time
Reason
The parent is responsible for assuring all medication/s, prescription or non prescription, is supplied and accompanied by a written note specificying the medication dosage and the time it is to be given. (i.e. Bee sting medication, Ritalin, Insulin, Inhalers, seizure medication, etc). All medication must be provided in its original container or package and marked with the student's name.
I/We acknowledge that there may be some element of risk involved in the above specified trip;therefore I/We release Caravel Academy Inc., for any liability that may occur as a result of this trip. A current Medical/Health InsurancePlan covers this child. I am/We are aware that Caravel Academy requires all participants on this trip to supply the following information in case a medical emergency should arise on this trip.*

I have read, understood, acknowledge and confirm all the information given in this form.
Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
Should be Empty:

Caravel Academy Music Department Permission Slip & Medical Authorization Form