Exhibit IFCB-2 (Print front & back)
(WBOP)

COBB COUNTY
MEDICAL HISTORY PERMISSION AND RELEASE FORM


Student Name: ___________________________________________________________ Age: _______________________

Address: __________________________________________________ Phone: ____________________________________

In case of emergency, notify:___________________________________ Phone: __________________________________

Family Physician:_____________________________________________ Phone: ___________________________________

Family Insurance Co:_____________________________________ Policy #: ______________________________________

Insurance Co. Address: _______________________________________Phone: ___________________________________

Immunizations: Tetanus ______Polio Booster_______ Measles_______ Mumps _________Other_______

Past Medical History: Asthma _____Sinusitis ___Bronchitis_____ Kidney ____Heart____ Diabetes______

                                        Dizziness ____Stomach Upset____ Hay Fever_____ Other_____ 

Allergies: Food_________________________  Insect bites/Stings ______________________________________________

Penicillin or other drug (name) ___________________________________________________________________________

Poison Sumac, Oak, Ivy______________________ Other _____________________________________________________

Previous operations/recent injuries/illness:__________________________________________________________________

Daily/Current Medications: ______________________________________________________________________________

Special Diet (name)/Restrictions: _________________________________________________________________________

Childhood Diseases: Chicken Pox ___________Measles _________Mumps______ Whooping Cough ______

Any medical needs your child has, of which adult supervisors should be aware:___________________________________

_____________________________________________________________________________________________________

Mother's Name:______________________ Home # ________________Work #____________________________________

Father's Name: ______________________ Home # _________________Work #___________________________________

 

 

   

 

 

     

(Back)
Permission for Treatment

A WBOP (Walton Band and Orchestra Parent) representative may give the following over-the-counter medications to treat common conditions, such as diarrhea, headaches, menstrual cramps, upset stomach, muscle aches, etc: PLEASE STRIKE THROUGH OR SPECIFY ANY MEDICATIONS YOU DO NOT WANT YOUR CHILD TO RECEIVE:
                    Acetaminophen (Tylenol)                Ibuprofen (Advil)
                    Sudafed                                        Aleve
                    Benedryl                                       Tums
                    Pepto Bismal                                 Midol

  

My permission is granted for school supervisors to obtain necessary medical attention in case of sickness or injury of my Student.  I release and waive, and further agree to indemnify, hold harmless or reimburse the Cobb County School District, the Board of Education, its successors and assigns, its members, agents, employees, and representative thereof, as well as trip supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the student or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, from any losses, damages or injuries arising out of, during or in connection with the student's participation in the trip or the rendering of emergency medical procedures or treatment if any.

 

DATED this ___________________________ of _________________, 200____.

________________________________________       ___________________________________________
Signature of Parent/Guardian                                                        NOTARY

 

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