Medical Release

West Salem High School

1776 Titan Drive NW Salem, OR 97304 503 399-5533

HEALTH FORM

Student Name: Last, First, M.I.
Date of Birth:
Name of Parent/Guardian:
Phone:
Emergency Contact:
Phone:
Does student have School Insurance?
Yes No
Type:
Parent/Guardian Insurance:
Company/Policy no.
Food Allergies:

Medication(s) Allergies:

What medications does student take:


Does student need chaperone to dispense medication? Yes No , If yes, please send medication(s) and instructions for dosage, frequency, and time of day to be dispensed.
Has student had medical attention or seen a doctor about (Circle all that apply):
Epilepsy Rheumatic Fever
Dizziness/fainting spells Asthma
Eye, Ear, Nose/Throat Trouble Palpitation of heart
Frequent colds Jaundice or Hepatitis
Hay fever Kidney or Urinary Trouble
Diabetes Bee Sting Allergies
Stomach Trouble Other

The school has my permission to call my family physician or another physician in an emergency when family physician or I cannot be contacted.

Name of Family Physician
Phone:
Alternate Physician:
Phone:

CAUTION

By law, a parent cannot consent in advance to any and all manner of emergency care. It is understandable that in cases, other than the need for immediate emergency treatment, the attending physician may defer treatment pending the parent’s express permission to administer specific professional service.

My student has my permission to travel with the West Salem High Print student Name School Choir Department to San Francisco May 25 – May 30, 2017. We have read the “Rules of the Road” and agree to abide by them on the trip.
Print Parent/Guardian
Date:
Signature Parent/Guardian:
Date:

RETURN TO MS. MAC BY Friday May 19, 2017.

Fill out paper form

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