2018-19 UHS Band Contact Info & Permission
Contact Info & Medical Emergency Permission Form
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's Graduating Class *
Student E-mail *
Use preferred address; will be used for regular communication.
Your answer
Student's Cell Phone
Your answer
Student will be in which of the following Concert Bands *
Parents'/Guardians' Names *
Your answer
Parents' E-mail *
Use preferred address; will be used for regular communication. Separate multiple e-mails with a comma.
Your answer
Parents' additional e-mail addresses *
Separate multiple e-mail addresses with a comma.
Your answer
Parents' Cell Phone *
Your answer
Parents' Place of Employment
Your answer
Parents' Work Number
Your answer
Alternate Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Student Allergies
Your answer
Other Student Medical Concerns
Your answer
Will the student require medication when traveling with the band? *
Can the student assume responsibility for taking own medication? *
Write any additional health or medical concerns here:
Your answer
Efforts will be made to contact parent/guardian prior to emergency service
In case of emergency, I give permission for qualified medical treatment to be given to the above-named child. I hereby give my permission for the above-named child to attend all band field trips and acknowledge that all school rules relative to student behavior are in effect throughout the trip. *
By clicking yes, you agree to the statement above.
Insurance Provider *
Your answer
Insurance Policy No. *
Your answer
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