Band Camp Registration

Student Information

First Name

Middle Initial

Last Name

Birth Date

Student HOME Address

Zip Code

Student Cell Phone Number

City Check Spelling

Grade next Fall

T-Shirt Size (required) X-Small Small Medium Large X-Large XXL XXXL

Instrument Section

Parent/ Guardian 1 Information

First Name

Last Name

Address

City

Zip Code

Home Phone Number Enter your area code and phone number (231)555-2121

Work Phone

Cell Phone

Parent/Guardian 2 Information

First Name

Last Name

Home Phone

Cell Phone

Student Medical Information

Additional Emergency Contact

Additional Emergency Contact Phone Number

Accident/Health Insurance Holder Name and Relationship to Student

Group #

Medical History

Allergies (required) Yes No

If Yes, List

Asthma (required) Yes No

Diabetes (required) Yes No

Heart Disease (required) Yes No

Medications (required) Yes No

If Yes, List

Date of Last Tetanus Shot

Student's Blood Type

Final Consents and Acknowledgements

By checking this box I give permission for my son/daughter to receive emergency care at an appropriate medical facility designated by the supervising teacher and/or administrator, in accordance with school board policy 7490. (required)

By Checking this Box, I acknowledge that my child and I have read, understand, and will adhere to all information and policies as outlined in the PHS Band Handbook (required) Please check at least one option

By checking this box I acknowledge that I will be financially responsible for all Petoskey Band issued instruments/uniforms/equipment assigned to my child. Replacement/ repair costs are determined by the directors/reputable repair shops/merchant dealers. (required) Please Check at least one option

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