The CHS Band Permission / Consent Form
Abilene Independent School District
The Cooper High School Band
Permission/Consent Form
Please Type or Print:
Student's Name: ___________________________________________________
Parent/Guardian's Name(s): ________________________________________
Home Address: _________________________________________________
Parent / Guardian Phone Contacts:
Home: ____________________ Cell #1: ___________________ Cell #2: ___________________
Other Emergency #: __________________
Student’s Date of Birth: ______________
Height: ____ Weight: ____
Physician: ________________________ Phone: ______________________
Insurance Company: ____________________ Policy #: _________________
Employer’s Name (if group): ________________________________________
Other Insurance Information:
__________________________________________________________________
__________________________________________________________________
PARENT/GUARDIAN: PLEASE INITIAL BESIDE EACH SECTION
___ 1. I give permission for my child to participate in on/off campus activities as a member of the CHS Band.
___ 2. I am aware that participating in the CHS Band may require my child to be at band activities before school, after school, and weekends. I also understand that some trips will take place out of town.
___ 3. I agree that Cooper High School, Abilene ISD, and/or their representatives shall not be held liable for any accident, injury, and/or illness my child may have while involved with CHS Band activities and shall be my responsibility.
___ 4. If my child is a victim of an accident, injury or sudden illness, and I cannot be reached by reasonable means, I hereby grant and authorize representatives of the AISD and/or CHS Band to take whatever measures are necessary for the emergency treatment of my child. I understand that these measures may include emergency surgery, medications, or whatever is deemed necessary by emergency medical personnel or attending physician.
___ 5. I also give permission for my child to be given over-the-counter medications as deemed necessary.
6. List ALL MEDICATIONS that my student is currently taking regularly:
__________________________________________________________________
__________________________________________________________________
7. List ALL KNOWN ALLERGIES including allergies to medications:
__________________________________________________________________
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8. List any known MEDICAL PROBLEMS/CONDITIONS:
__________________________________________________________________
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PLEASE INFORM MR. JOHNSON OF ANY CHANGES DURING THE YEAR
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Parent/Guardian Signature, Date
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Student Signature, Date
