The purpose of this form

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This form is required for all students who may be involved in an activity including rehearsals, performances, and travel with the DMHS Performing Arts Department this school year. In the event that we need to seek medical care for your student, please provide complete and accurate information. All information will remain confidential and will only be shared with care providers as needed for the health and safety of individual students. The last section is an additional media release form in addition to that which is required by the school.

Student LAST NAME *

Student FIRST NAME *

Mailing address *

City *

State *

Zip Code

Student Email (NOT your school email, but another that you will check frequently) *

Student Cell Phone *

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