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    Fillable Coppell HS Band Medical Form

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    saanvi.chiliveru

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Fillable Coppell HS Band Medical Form

    Uploaded by

    saanvi.chiliveru
    13 views1 page

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    13 views1 page

    Fillable Coppell HS Band Medical Form

    Uploaded by

    saanvi.chiliveru

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Coppell HS Band Medical Form

    Satish
    I, _____________________ Saanui Chiliveru
    Chiliveru give my child __________________________ permission to
    participate in the supervised activities of the Coppell HS Band during the 2024-2025 school
    year. I understand the Band Directors employed by Coppell ISD will supervise the activities. I
    authorize the Coppell HS Band Directors to act on my behalf if an accident occurs and my child
    needs medical attention.

    I hereby release the Coppell HS Band Staff, Coppell ISD, and its employees, any parent hosts,
    and volunteer sponsors from any and all liability and responsibility in connection with accident or
    injury to my child while with the Band on any official function, trip, or activity.

    PLEASE PRINT THE FOLLOWING INFORMATION CLEARLY


    Student’ Full Name _____________________________________
    Saanui Chilivero 11th
    Current Grade ____________
    Address _________________________________________ DOB _____/_____/_____________
    I 5
    City/State/Zip ___________________________________ School ID# ____________________20
    as
    Parent/Guardian Full Name _______________________________________________________
    Mobile Phone 1 Name _______________________ Number _____________________________
    201 916 0708
    ve fh
    Mobile Phone 2 Name _______________________ Number _____________________________
    Mobile Phone 3 Name _______________________
    201 916 0709
    Number _____________________________
    Saanui Chilivery
    Mobile Phone 4 Name _______________________
    945 345 9123
    Number _____________________________
    Praneeth Dasari 201 245 8382
    Doctor’s Name _____________________________ Phone ______________________________
    972 481 6400
    Micki's Y Isha
    Insurance Company ______________________________________________________________
    c
    Please list any restrictions, allergies, or special medical conditions
    N A
    ______________________________________________________________________________
    ______________________________________________________________________________
    Is your student taking any medications at this time? YES / NO If YES, please list medications
    currently being taken (prescription and over-the-counter)
    ______________________________________________________________________________
    ______________________________________________________________________________
    RELEASE: I hereby grant permission for the caregiver to administer my child prescription
    medication as directed by his/her physician.

    Seth
    Parent/Guardian Signature _______________________________________________________

    17 2024
    Date _____/_____/________
    07

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