Name (Last, First MI) _ , ___ _

Street Address ____________________________________________________________

P.O. Box __________ (if applicable)

City, State Zip _________________________________ , ____ ________________

Parent/Guardian ____________________________________________________________

Contact Numbers: Home ( ) _____-________ Work ( ) _____-________ Cell ( ) _____-________

In case of an emergency, I hereby give Mr. Cory Boltz of Mardela Middle and High School of Mardela Springs, MD 21837, permission to administer first aid to my child and authorize him to sign permission for medical treatment. In the event that the Band Director cannot be located, permission is also granted to the Chaperones of Mardela Middle and High School Band. I understand that they will be acting in the best interests of my child and I will abide by their decision. In accordance with the decisions made by the above mentioned people, I will not hold them responsible for any decisions they make.

Parent/Guardian Signature _ Student Signature _

Student Date of Birth Student Date of Last Tetanus __

Insurance Co. ________________ Policy # _ ________ Phone ( ) _-______

In the event it is impossible to reach the parent/guardian, please list two (2) people that can be contacted, if necessary.

Name Name

Phone ( ) _-__ Phone ( ) _-______

Relationship _________________________ Relationship _________________________

IMPORTANT!! Please list any medications of any type that your child is currently taking

(please contact Band Director anytime to add or delete throughout the year).

Please list any allergies or other substances that your child is allergic to (e.g. bee stings, penicillin, foods, sunburn, seasonings, etc.) Also, please list anything that may upset the normal routine of your child.

IMPORTANT!! Please list any medical information that should be known about your child—anything that may cause extra attention in the case of an emergency (e.g. bad asthma attacks, cramps, severe headaches, feet/arm problems, etc.)

Attach extra info as needed. NO bandsman will travel without this form completed. This is for the protection of the child.

[Return this and all information sheets by Tues, August 5, 2008 (Band Camp Evening #1)]

Return

Name (Last, First MI) _________________________ , _____________________________ ___

Street Address ____________________________________________________________

Parent/Guardian Signature _______________________ Student Signature _______________________

Student Date of Birth ________________ Student Date of Last Tetanus __________________

Insurance Co. __________________ Policy # ___ __________ Phone ( ) _____-________