1. EMERGENCY RELEASE / EMERGENCY CONTACT / MEDICAL INFORMATION FOR A CHILD
ALTERNATE EMERGENCY CONTACTS
___________________________________________
Student Name
___________________________________________
Parent/Guardian Name Relationship
Home ( ) ________________________________
Cell ( ) ________________________________
Work ( ) ________________________________
___________________ Male _____ Female ______
Date of Birth
____________________________________________
Parent/Guardian Name Relationship
Home ( ) __________________________________
Cell ( ) __________________________________
Work ( ) __________________________________
STUDENT LAST NAME _______________________________
___________________________________________
Emergency Contact Name Relationship
Home ( ) ________________________________
Cell ( ) ________________________________
Work ( ) ________________________________
MEDICAL INFORMATION
_____________________________________________
HOSPITAL / CLINIC PREFERENCE
_____________________________________________
PHYSICIAN’S NAME PHONE NUMBER
______________________________________________
INSURANCE COMPANY PHONE NUMBER
______________________________________________
POLICY NUMBER / GROUP NUMBER
I hereby grant the Fallbrook Union High School parent volunteers, staff, physician, or other medical
personnel, or any person connected to the school, to determine if emergency care is needed for my child
while participating in band, color guard, or other related activities. I further understand that every reasonable
effort will be made to contact the legal guardians, or emergency contact listed on this release, prior to and
treatment is given.
I give permission for my child to attend field trips. I release Fallbrook Union High School and individuals
from liability in case of accident during activities related to the Instrumental Music Program, as long as
normal safety procedures have been taken.
______________________________________ _____________________________________
Parent’s / Guardian’s Signature Date
___________________________________________
Emergency Contact Name Relationship
Home ( ) ________________________________
Cell ( ) ________________________________
Work ( ) ________________________________
_______________________________________________________________________________________________
MEDICATIONS
_______________________________________________________________________________________________
KNOWN ALLERGIES OR MEDICAL CONDITIONS WHICH WOULD LIMIT PARTICIPATION