Student Last Name, First Initial: _______________________________________Grade: _________
Student cell phone: ____________________________________
I understand that accidents and illnesses occur. If "YES" below, the chaperones may administer this over-the-counter medication to my child. If "NO" below, the chaperones may not administer this over-the-counter medication to my child. Medications may be generic. Indicate Yes or No for EVERY medication.
Special Dietary Requirements: ______________________________________________
Please list the name and dosage of any medication (prescription or over-the-counter) your child will need on trips. First-aid chaperones will hold all medications to be given and each med should be in a separate Ziploc bag clearly labeled with the student’s name, the medication, the dose, and the times to be given. If, after turning in this form, you discover your child will need to take a medication not listed, please contact the first aid chaperones as soon as possible. Medication
Dosage (s)
Time(s) (e.g.,
8 a.m., p.m.)
Both the student and I understand that the student is NOT allowed to have medication in his/her possession, with the exception of an inhaler for asthma or an epi-pen for severe allergies, or insulin for diabetes. By signing below, I authorize the adult in charge or designated personnel to administer the above-listed medications to my child should he/she need or request them. In case of illness, accident or an emergency, I authorize the band director, or assigned parent chaperones or personnel, to secure any and all necessary medical/dental treatment for my child while he/she is participating in any activity of the Herndon High School Band. I also guarantee payment of all charges incurred during this medical/dental treatment (including, but not limited to: physician, hospital, x-ray, lab, drugs, ambulance). I hereby authorize the Band Director or any agent of the Herndon High School Band Parents Association responsible for student welfare to access the information contained in these medical forms for my child’s my well-being. I acknowledge that participation in marching band involves strenuous physical activity and interstate and/or intrastate travel posing the danger of injury and illness to band participants and assume the risk of such dangers. I agree that the Fairfax County Public Schools, the Herndon High School Band Parents Association and their agents and/or employees shall be in no way responsible for any illness or injuries suffered by my child while engaged in any band activity sponsored by Herndon High School Band. Further, I hereby release and hold harmless the aforesaid of any and all responsibility and liability for the administration of the above listed medications or any injury or claim resulting from participation in any band activity.
DATE: _____________

Source: http://herndonband.net/wp-content/uploads/2012/06/First-Aid-fill-save.pdf


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