Marshfield Public Schools Music Department AUTHORIZATION FOR SCHOOL REPRESENTATIVE TO ACT ON BEHALF OF ABSENT PARENT/GUARDIAN Music Dept. trip to So. California area April 11-16, 2019
Please do one form for each participating student
Student First Name *
Your answer
Student Middle Initial *
Your answer
Student Last Name *
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Student's Primary MHS Music Teacher *
Parent/Guardian Name *
first and last please
Your answer
Family Mailing Address *
street, city, ZIP
Your answer
Student Preferred E-mail Address *
For all e-mail communication about the trip
Your answer
Parent/Guardian Preferred E-mail Address *
For all e-mail communication about the trip
Your answer
Optional Additional E-mail Address
For all e-mail communication about the trip
Your answer
Home Phone Number *
answer "000-000-0000" if you do not have one
Your answer
Parent/Guardian Cell Phone Number *
answer "000-000-0000" if you do not have one
Your answer
Parent/Guardian Work Phone Number *
answer "000-000-0000" if you do not have one
Your answer
Student Cell Phone Number *
answer "000-000-0000" if you do not have one
Your answer
Emergency Contact #1 Name *
Your answer
Emergency Contact #1 Phone Number *
Your answer
Emergency Contact #2 Name *
Your answer
Emergency Contact #2 Phone Number *
Your answer
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