FIU Marching Band Medical Release Form

Permission for Medical Treatment Form
I the undersigned, being a participant of the FIU Marching Band do hereby authorize any necessary medical treatment for myself while participating in the FIU Marching Band Program. I also guarantee payment of all charges incurred during this medical treatment, (doctor, hospital, x-ray, lab work, ambulance, medications, etc.) In consideration of the FIU Marching Band and Staff for accidents, injuries or damages as a result of my participating in said activities.

Name Name First Last
Phone Number
Email
Date of Birth Date of Birth / MM / DD YYYY
Any known allergies to foods, medications, insect bites. (If none, type N/A) Please briefly list allergic reaction
Special medical problems or conditions (if none, type N/A)
Is participant currently on any medication

Is participant currently on any medication Yes No
List all medication(s) and daily dosage brought to camp or on trip, including non-prescription medicines. If none, type N/A.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY