Oxford High School Theatre Medical Information Form by 3WB757y


									         Oxford High School Theatre Medical Information Form

Student Name: (Please Print):__________________________________

Parent or Legal Guardian Name:________________________________

Emergency Phone #:___________________________(Home)


Name of Insurance Co.:___________________________________

Insurance Policy #:______________________________________

Phone # of Insurance Co.:_________________________________

Are you taking any medication on a regular Basis? _______(Yes) _______(No)

         IF YES, please list drug name, dosage and interval:__________________

Name and phone of attending Physician:_________________________________

Please list any allergies or known drug reactions:

Please list any medical condition, which you feel should be known:

In the event of an emergency, we the parents or legal guardians of__________________________
give our permission for John Davenport, Director of the Oxford High School Theatre Program, to
administer or arrange for first aid and if necessary arrange for emergency medical attention for our
child. We agree to pay the full cost of any needed medical attention and understand that every
reasonable effort will be made to contact us prior to treatment. We also agree to release and
discharge the Oxford City School Board, is officers, agents, and employees exercising reasonable
care within their scope of employment, from liability (all claims and demands/rights and causes of
action) growing out of personal injuries and property damage resulting or occurring during this
activity or in transit to and from said activity. (Notary Seal should be placed at bottom Right

Date:____________ Signature of Parent or Guardian:_____________________

                                                                         Notary Seal

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