Band Medical Release Form

							                                   MEDICAL RELEASE FORM
Students Full Name:
Address:                                 City                             Zip:
Birthdate:      /       /         Present Age:_        Grade: _____ School:
Father’s Name:                                    Mother’s Name:
Legal Guardian is:                                Home Phone (            )-     -
Family Physician:                                      Phone: (           )-     -
In case of emergency, other responsible relative:
Phone: (        )-      -                 Relationship to Student:
School Insurance? YES or NO (circle one)
Family Insurance Company:                              Policy #:

                                       MEDICAL HISTORY
Known Drug Allergies:
General Anesthesia Allergies:
Other Known Allergies:
Medical condition(s) currently under treatment:


Medication(s) currently in use:
Physical disabilities (i.e. asthma, diabetes, etc.):


Recent surgery: (When and what)
Last Tetanus shot/booster date:
Special health problems:


        I, parent/guardian of                                , give my permission to the Edenton-
Chowan Band Parents, Inc., to act as guardian in the event of an accident involving my child and
I am not able to be contacted. Also, in the event of an emergency, ECBP, Inc., has my
permission to consent to any attending physician to administer to my child any medications or
perform any treatments that he/she deems necessary for the proper care and well-being of my
child.
        In consideration for the services performed by Edenton-Chowan Band Parents, Inc., the
aforementioned parties are herewith released from liability for all actions taken in good faith
during the event.

Parent/Guardian:                                                  Date:

Parent/Guardian signature: