Microsoft word - band trip emergency form-chaperone

RIVER FALLS HIGH SCHOOL BAND CHAPERONE 2010-2011
Emergency Information
Please Print
Chaperone’s Name: _______________________________________________________________ Home Address: __________________________________________________________________
Home Address:____________________________________________________________________
Spouse/Significant Other’s Name: _____________________________________________________
Home Phone #:______________ Work Phone#:_______________ Cell Phone #: ________________
IN CASE OF EMERGENCY, THE FOLLOWING SHOULD BE CONTACTED:

Contact #1: ___________________________________
Contact #2: ___________________________________ Family Doctor: ________________________________ Family Dentist: ________________________________ Do you wear prescription glasses or contacts? Yes _____ Do you have motion sickness tendencies? Yes_____
ALL MEDICAL INFORMATION IS KEPT CONFIDENTIAL

Please list any/all medical conditions that emergency personnel should be aware of:
(i.e. allergies, drug allergies, asthma, diabetic, special health needs, etc.) □ NONE

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list all medications taken on a regular basis (Please list conditions for which they are taken,
dosage and frequency. Please include inhalers.) □ NONE
______________________________________________________________________________
________________________________________________________________________ OVER 

The following items are items that we will have available in our travel health kit. Please review this
list and circle any items that you would NOT like your child to receive:
TYLENOL

Insurance Information:

Primary Carrier of Insurance: Yourself _____ Spouse/Significant Other _____
Name: _______________________________________________Birthdate:________________
Place of employment: ___________________________________________________________ Insurance Company Name: _______________________________________________________ Insurance Company Address: _____________________________________________________ Insurance Company Phone #: _____________________________________________________ Insurance Policy #: _________________________ Insurance Group #: ___________________ Other pertinent insurance information: ________________________________________________________________________________ ________________________________________________________________________________ If impossible to contact any of the contacts listed on the reverse side, I give permission and consent to the River Falls High School Marching Band Director(s) or Chaperone(s) to call the rescue squad, arrange for immediate medical treatment by licensed physician and/or other medical personnel, and for such physician or other medical personnel to apply such emergency techniques which in their judgment they deem necessary to treat any injury/illness sustained by myself. I further authorize any and all emergency medical treatment as is necessary for the health and welfare of myself. I do hereby agree to hold harmless and indemnify the River Falls School District, directors, and chaperones and its members from all claims, demands, damages or causes of action or injuries, including reasonable attorney’s fees and costs in the defense thereof, arising out of the physician and/or other medical personnel. _______________________________________________________ _______________________________________________________

Source: http://www2.rfsd.k12.wi.us/high/hs_departments/music/Band/Florida%20Trip/Band%20trip%20emergency%20form-chaperone.pdf