Round Rock High School ROCK Guard 2007-2008

Permission Slip and Health Form

This permission slip is used to authorize your student to travel with the Round Rock High School ROCK Guard. School authorities, parent chaperones and staff accompanying the student on trips throughout the 2007-2008 winterguard season may need to use the medical information.

**************************************************************************************************

Student Name_______________________________________________________________________________________

Home Phone______________________________________Secondary Phone____________________________________

List any allergies_____________________________________________________________________________________

List any medications that your child IS taking______________________________________________________________

__________________________________________________________________________________________________

List any medications that your child may NOT take__________________________________________________________

__________________________________________________________________________________________________

Does your child have any health conditions that may limit their participation in any activities? If so, please explain______

__________________________________________________________________________________________________

May the chaperone(s)/staff provide the following to your child on request? (circle each)

Aspirin Yes or No Pepto Bismol Yes or No

Ibuprofen Yes or No Aleve Yes or No

Throat lozenges Yes or No Tylenol Yes or No

Cough suppressant Yes or No Acetaminophen Yes or No

Date of last tetanus immunization, month/year_______________________________Parent intials___________________

Does you child wear contact lenses and/or removable dental appliance?_________________________________________

**************************************************************************************************

Parent / Guardian Name_______________________________________________________________________________

Parent / Guardian Telephone_______________________Work______________________Other_____________________

List a responsible adult to contact in the event a parent / guardian cannot be reached:

Name________________________________Relationship_________________________Phone______________________

Student’s Physician__________________________________Office Phone_______________________________________

Insurance Company_____________________________________________Phone________________________________

Address_________________________________________________Policy/Group #_______________________________

Name of insured_____________________________________________________________________________________

**************************************************************************************************

I hereby grant permission for my child (named herein) to participate in trips involving some water related activities. I understand that this activity does expose my child to the risk of injury or death. I further understand that participation in these trips will involve activities off of school property and that neither the Round Rock Independent School District nor its employees will have any responsibility for the condition of non-school property.

Furthermore, if immediate observation or treatment is urgent in the judgment of school authorities, I authorize and direct the school authorities to send my child, properly accompanied, to the hospital, doctor or dentist most accessible. I further agree to reimburse RRISD, Round Rock High School or the Round Rock High School Band Boosters for any medical expenses that may be incurred by my child while they are participating in these activities.

I hereby grant permission for my child to participate in all aspects of these field trips (circle one) EXCEPT / INCLUDING, any activities that are water-related.

Parent / Guardian signature_________________________________________Date_________________

**************************************************************************************************