PERMISSION and INSURANCE STATEMENT
SANDALWOOD BAND

________________________________________, Birth date _____/_____/________
		(PRINT student name)		          month  /  date  /  year

S.S. No. __ __ __ - __ __ - __ __ __ __ is hereby granted permission by ____________________________
								     (PRINT Parent/Guardian Name)

to participate in Band and all school-approved Band activities during the 2005-2006 school year.

I authorize my child to accompany the Band on local or out-of-town trips using school-approved transportation.  I further authorize the school Band directors or the sponsor/instructor(s) to obtain, through a physician of his or her choice, any emergency medical care that may become reasonably necessary for my child as a result of practice or performance participation.  This includes any activity occurring on field trips and/or on-campus activities.

Furthermore, I/we authorize the school Band directors or sponsor/instructor(s) to administer any of the following “over the counter” medications to my child during field trips and/or non-campus activities. (If you do not fill out any of the below, none will be allowed to be administered to your child).

____ Tylenol		____ Motrin		____ Immodium		____Benadryl	

____ Advil Sinus & Cold	____Pepcid		_____ Mylanta		_____ Tums

(OR GENERIC EQUIVALENT OF ABOVE) ___________


We have medical insurance with: _________________________________   Policy #: __________________
(or photocopy card and attach)	(name of insurance company)

Address:	____________________________________City/State  __________________  Zip ___________


____ I/we do not have medical insurance, however, I/we will pay any and all medical bills for emergency care of my child.  
If neither of the above is checked, this form is invalid, one or the other must be checked.


Our family physician is: ___________________________________  Phone: _________________________
	
Address:   ___________________________________ City: _____________________  Zip _____________

If you do not have a family physician, check here: ___________

In regard to the above named student, I submit the following information:

1. Allergies to foods, medications, etc.		If none, please write NONE


2. Special medical problems.			If none, please write NONE.


3. Is student on any continuing medication (such as inhalers, etc.)?  If so, please state and describe dosage required.


4. Date of last known tetanus shot ____________________________________

I/we are also aware of day to day risks that are involved in extra-curricular participation, and will not hold The School Board of Duval County, Sandalwood High School, or individual directors and/or sponsors responsible for any injuries that may be sustained from participation.

Parent/Guardian signature: _____________________________________________________________

Phone (Home) ________________ Phone (Work) ________________ Phone (Cell) _______________

Address: ____________________________________ City ___________________ Zip _____________

Emergency Contact: ___________________________________ Phone: _________________________

Do not fill in below this line.  To be filled in by Notarizing Agent.


NOTARIZATION:

State of Florida, County of _____________.  Sworn to and subscribed before me this _______  day of 

_________________, 20_____.	Notary Signature: __________________________________

Seal: