Jazz Band Clinic Day Registration 2019
By completing and submitting this registration form, I hereby give permission for my son/daughter to attend the Downriver Music Guild Jazz Clinic Day, on Tuesday, March 26th, at Gibraltar Carlson HS. However, Should an accident or injury occur while on the trip, I give my permission to have my son/daughter treated. I accept the responsibility for any medical bills incurred as well as the cost for transportation by means of ambulance or motor vehicle to a hospital, if necessary. I accept all responsibilities while my son/daughter is participating in this field trip.

I understand that this field trip will take place during the normal school day, and that my child will be responsible for all classwork missed and will use their normal mode of transportation home that afternoon.

This form must be completed, and the $10 registration fee (per sutdent) delivered to Mr. Mobley, by THURSDAY, MARCH 14. Please pay fee via exact cash or check, made out to Brownstown Middle School. If sending payment for Mudhens registration as well, please make two checks, or two seperate cash payments.
Student Name (last, First) *
Your answer
Student 2 Name (last, first) if appicable
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Parent Name *
Your answer
Parent Email Address *
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Parent Cell Phone Number *
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Emergency Phone Number
If different from Parent Cell Phone Number
Your answer
Health Insurance Provider
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Group Number
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Contract/Policy Number
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Other Numbers (if any)
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Name of relative to contact if you cannot be reached in an emergency *
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Their cell phone number *
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TOTAL DUE
$10 per student. Please send in as cash (exact change) or check, made out to Brownstown Middle School. Payment and registration due by Friday, March 10.
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