Please read and sign the following consent form for medical treatment:
Should medical care be needed for my child
(Name of child)
The Minnesota State University, Mankato band staff will make every effort to contact me
for directions as to that care. In case of a medical emergency, I hereby authorize the
Minnesota State Mankato staff to obtain urgent emergency medical care for my child
during the Minnesota State, Mankato High School Honor Band on January 22, 2016.
I understand that I will be responsible for the payment of any medical expenses incurred
by my child during the Honor Band day.
Medical Insurance Carrier:
Policy Number:
_______________________________________________
_____________________________________________________
Relationship to Student:
_______________________________________________
Special medical needs or concerns: _________________________________________
_______________________________________________________________________
Name and phone number in case of emergency:
_____________________________
_______________________________________________________________________
Parent/Guardian Signature:
_______________________________________________
Please bring the Medical Form with you on Friday, January 22, 2016.