Final 2014 hc registration letter, forms (page 03).pdf

MEDICAL PERMISSION FORM
NC-ACDA Honor Choir • Des Moines • March 20-22, 2014 Required of all participants.
Participant’s Name: _____________________________________________________________________________________ Health Insurance Provider: ______________________________________Policy Number: ____________________________ List al prescription medications you are currently or might be taking: Name: ______________________________ Dosage: __________ Frequency:_____Reason:_____________________ Name: ______________________________ Dosage: __________ Frequency:_____Reason:_____________________ List any known food, drug, animal, or environmental al ergies: ______________________________________________________ Circle any conditions for which the participant is currently receiving medical treatment: Insulin Dependent Insulin pump Fainting Inhaler Auto Immune Disorders ADHD ADD Depression Other: _______________________________________________________ List any other medical conditions for which the participant is being treated:____________________________________________ _______________________________________________________________________________________________________ Physicians Name:______________________________________________ Of ice Phone: (______) _______________________ Address:_____________________________________________________ Home Phone: (______) _______________________ Cel Phone: (______) _______________________ The designated Honor Choir Chair, Honor Choir Chair Assistant, and/or Honor Choir Coordinator, and the designated chaperone (if other than a parent) have my permission to administer (dual person observed and documented) the fol owing to the participant if warranted: (Circle) Tylenol Ibuprofen Imodium Dramamine Pepto-Bismol Maalox Tums Other: ___________________________________________________ If you wish to be cal ed before any over-the-counter medication is dispensed, please initial here: _____ If the participant listed above should require medical attention while participating in the NC-ACDA Honor Choirs in Des Moines, Iowa, March 20-22, 2014, NC-ACDA staf and/or the designated chaperone has my permission to treat on-site or take said participant to a doctor, hospital, or any other medical facility for necessary medical treatment, and I hereby authorize the release of medical information included on this document to the health care provider administering medical treatment to the participant. I hereby release, indemnify and hold harmless the American Choral Directors Association (“ACDA”), its trustees, employees, volunteer workers, students, agents and assigns from any and al liability, damage, claim of any nature whatsoever arising out of or in any way related to my/my child’s participation in the NC-ACDA Honor Choirs in Des Moines, Iowa.
Participating in any activity is an acceptance of some risk of injury. I agree that my/my child’s safety is primarily dependent upon taking proper care of oneself. Despite precautions, accidents and injuries may occur and injury and/or loss or damage to personal property may occur as a result of participating in the NC-ACDA Honor Choirs; therefore, I assume al risks related to participating in the NC-ACDA Honor Choirs. I also hereby acknowledge that the American Choral Directors Association, its trustees, employees, volunteer workers, students’ agents and assigns assume no liability whatsoever for personal injuries or property damage that may arise out of my/my child’s participation in the NC-ACDA Honor Choirs. My signature on this form indicates that I have read, understood, and freely signed this agreement. I expressly agree that this agreement shal be construed and enforced in accordance with laws of the State of Iowa, with Polk County being the court of exclusive jurisdiction, and I consent to the jurisdiction of the State of Iowa and the courts of Polk County. I agree that this waiver and release is intended to be as broad and inclusive as permitted under the laws of the State of Iowa so that if any portion hereof is held invalid, the balance shal continue in ful legal force and ef ect. Name (Print): ___________________________________ Signature: _____________________________________ Home Phone: (_____) ___________ Cel Phone: (_____) ___________ Work Phone: (_____) ___________ Other Phone:(_____) ___________

Source: http://ncacda.org/sites/default/files/FINAL%202014%20HC%20Medical%20Form.pdf