PLEASE PRINT THIS AND
RETURN IT TO MRS. MAGUIRE ASAP!

MEDICAL RELEASE FORM

RELEASE AND CONSENT
THE SCHOOL BOARD OF SEMINOLE COUNTY
 

This form must be read and signed by parents(s) or guardian(s) of every minor:

Re:  ____________________________________Date: School year 2009-10

I/We do hereby approve of my/our child attending all competition, community and commercial shows on behalf of the Seminole High School Dazzler Dance Team during the school year 2009-2010.

 I/We acknowledge that the school board of Seminole County, Florida, is not liable for medical expenses, hospital expenses or other such charges incurred for such services as may be rendered for or on behalf of my/our child as a result of injury or sickness.  I/We understand that if my/our child is injured or becomes sick, the school board of Seminole County, Florida will not be liable unless the injury or illness is he result of negligent conduct of the part of an employee of the school board of Seminole County, Florida.

Child’s Allergies: _________________________________________

Parent or guardian’s signature ________________________________

Date:  _____________________________________

Child’s Physician:____________________________________

Phone No. ___________________________  

Address:  __________________________________

Medical Insurance Co.: __________________________________________

_____________________________________________________________  

Phone No.: ________________________________

Policy Number:  ______________________    

Home:         ________________________________

Work:          ________________________________

Medication: __________________________  

Emergency Contact:  _________________________

Phone No.:  ________________________________

The Parent/Guardian is responsible for notifying the Dance Director (Maureen Maguire), or your parent representative at 320-5162 to report any changes in the above information.

You must have insurance to participate on the Dazzler Dance Team.

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