To Whom It May Concern: I, the undersigned, being the parent, legal next-of-kin, or legal guardian of _____________________ hereby authorize any necessary medical treatment for this person while on the H-B Woodlawn music trip. I also guarantee payment of all charges incurred during this medical treatment (physician, hospital, x-ray, lab, drugs, ambulance, etc.) and submit the following information.

 

1.      Allergies to foods, medications, etc. (If none, so state)

 

____________________________________________________________________

 

2.      Special medical problems (If none, so state)

 

____________________________________________________________________

 

3.      Does the participant carry medications on person? (If none, so state)

 

 

 

4.      Date of last Tetanus shot _________________________________________________

 

5.      Family physician _______________________________________________________

 

 

       City ___________________ State _____ Zip __________ Phone ________________

 

 

printed name of parent/guardian                                                                     signature

 

PARENT(S) ADDRESS: ________________________________________________

 

DAY PHONE ____________________ FATHER ______________________ MOTHER

 

NIGHT PHONE ___________________ FATHER _____________________ MOTHER