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Get Cobb County Form Ifcb 5

Medical History Permission and Release Form Form IFCB-5 Student Name Age Address Zip In case of an emergency notify Relationship Phone Cell Phone Additional contact person Phone Family Physician Phone Family Insurance Co. Policy Insurance Co. Address IMMUNIZATIONS Tetanus Polio Booster Measles Mumps Other PAST MEDICAL HISTORY Asthma Sinusitis Bronchitis Kidney Heart Diabetes Dizziness Stomach Upset Hay Fever Other ALLERGIES Food or other drug name Insect bites/stings Poison Sumac Oak or Ivy Other Previous operations or serious illnesses Any current medications Special Diet name Childhood Diseases Chicken Pox Measles Mumps Whooping Cough Any medical needs which your child has of which adult supervisors should be aware if so explain treatment If needed may we administer to your student check all that you approve Tylenol Advil Aleve Tums/antacid tablet Benedryl Sudafed Anti-itch creme PERMISSION FOR TREATMENT 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. Medical History Permission and Release Form Form IFCB-5 Student Name Age Address Zip In case of an emergency notify Relationship Phone Cell Phone Additional contact person Phone Family Physician Phone Family Insurance Co. Policy Insurance Co. Address IMMUNIZATIONS Tetanus Polio Booster Measles Mumps Other PAST MEDICAL HISTORY Asthma Sinusitis Bronchitis Kidney Heart Diabetes Dizziness Stomach Upset Hay Fever Other ALLERGIES Food or other drug name Insect bites/stings Poison Sumac Oak or Ivy Other Previous operations or serious illnesses Any current medications Special Diet name Childhood Diseases Chicken Pox Measles Mumps Whooping Cough Any medical needs which your child has of which adult supervisors should be aware if so explain treatment If needed may we administer to your student check all that you approve Tylenol Advil Aleve Tums/antacid tablet Benedryl Sudafed Anti-itch creme PERMISSION FOR TREATMENT 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..

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