Emergency Medical Release And Information Form printable pdf download

Emergency Medical Release and Information Form

To be completed at the beginning of each year.

Please complete and mail back to Children’s Chorus Office by August 1, 2011

The Frederick Children’s Chorus

10716 Etzler Mill Road

Woodsboro, MD 21798

Name of child: ____________________________________________________________

Chorus in which the child participates (circle)

LMM

Training

Intermediate

Concert

Chamber Singers

Age: __________

DOB: _____________

Name of Parent(s) or Guardian: ______________________________________________

Emergency Phone number(s) (list in the order you want us to make the calls and indicate if it is your home,

your work, your cell or another person.)

1. _______________________________________2. _________________________________________

3. _______________________________________4. _________________________________________

Relative who could be contacted if parents are unavailable: ________________________________

Relative’s Emergency Phone number(s): ________________________________________________

Medical Conditions and/or Allergies: __________________________________________________

____________________________________________________________________________________

If your child has a reaction to allergies mentioned above, what treatment should they receive?

________________________________________________________________________

Medical Insurance Information if the child requires Hospital Treatment. (Provider, group and member #)

________________________________________________________________________

Primary Care Physician: _________________________________Phone: _________________________

List any prescription medications administered regularly and attach instructions separately if medication is

to accompany the child to a rehearsal or on any trip.

________________________________________________________________________

______Check here if the child will self-administer. If child will self-administer, the chaperone assigned will

check with the child to be sure medication has been taken as indicated above.

Emergency Medical Release And Information Form