CVHS 2017-18 Instrumental Music Information Form
Welcome to the 2017-2018 Instrumental Program at Crescenta Valley High School!

Thank you in advance for taking the time to provide the information we need to compile all the "in house" paperwork needed to run the program throughout the upcoming year. Hopefully, this one online form should provide almost all the information we will need, and we will not have to send home much paperwork during the school year itself.

Please fill this form out completely. Complete separate surveys for siblings. Please write "NONE" in fields which you can't provide info (e.g if you have no cell number or no email...) Don't leave anything blank. Thank you!

Student First Name
Your answer
Student Last Name
Your answer
GUSD ID Number
Your answer
Graduation Year
Incoming Seniors - 2018, Juniors - 2019, Sophomores - 2020, Freshmen - 2021
Gender
Student Birthday - mm-dd-yyyy
Your answer
Class Student will be taking
Instrument
Your answer
Will you need to use a CV instrument?
Home - Street Address
Your answer
Home City
Your answer
Home Zip Code
Your answer
Home Phone Number - xxx-xxx-xxxx
(if none, type none - all phone numbers must be in this format xxx-xxx-xxxx)
Your answer
Student Cel Phone Number - xxx-xxx-xxxx
Your answer
Student Email Address
Your answer
Parent (Dad) or Guardian 1 First Name
Your answer
Parent (Dad) or Guardian 1 Last Name
Your answer
Parent (Dad) or Guardian 1 Cell Phone Number - xxx-xxx-xxxx
Your answer
Parent (Dad) or Guardian 1 Email Address
Your answer
Parent (Mom) or Guardian 2 First Name
Your answer
Parent (Mom) or Guardian 2 Last Name
Your answer
Parent (Mom) or Guardian 2 Cell phone Number - xxx-xxx-xxxx
Your answer
Parent (Mom) or Guardian 2 Email Address
Your answer
If student is in Marching Band, will they be attending "Band Camp"?
July 31-Aug11, 2017 -- Mon-Fri, 7am-3pm. (Band Officers, Color Guard & Drumline have additional times)
What size T-shirt do you wear (in adult men's size)?
So our uniform fitters can start figuring out sizes, please accurately measure and provide: Height, (barefoot) in inches
Your answer
Accurate Waist size, in inches
Your answer
Accurate Weight, in pounds
Your answer
In case of sudden illness or accident to this student, please contact Mother, Father, or Other Emergency Contact (Friend or Relative):
Required
Name of Other Emergency Contact
Your answer
Phone Number of Other Emergency Contact - xxx-xxx-xxxx
Your answer
If swimming or water activities are a part of a field trip or activity, I give permission for my child to participate in these activities.
My student's swimming ability is:
INSURANCE AFFIDAVIT GUSD does not carry student accident insurance. The information requested applies to coverage for medical and hospital expenses resulting from injury occurring during an instrumental event
Insurance Company Name:
Your answer
Insurance Policy #:
Your answer
Please list any serious illnesses, accidents, and/or chronic conditions (e.g. serious allergies, asthma, bleeder, diabetes, frequent fainting, heart condition, seizures, etc) that staff should be aware of, and please explain:
Your answer
Please list any extreme food allergies or medical dietary restrictions (not food preferences). We will try to accommodate food needs, however the safest course is always for student to bring their own food.
Your answer
Are there any special medications or drugs to be taken by the student, that staff should be aware of? All medications and drugs, except those which must be kept on the student's person for emergency use, must be kept and distributed by a staff member.
If YES, please LIST student's medications and/or drugs and reasons for taking them
Your answer
Students sometimes request non-prescription over-the-counter medications such as Tylenol, cough drops, etc. Do you give permission for staff to dispense OTC medications if needed or at your students request?
The following non-prescription medication(s) SHOULD NOT be administered to this student.
Your answer
Enter Parent Name below to serve as an electronic signature:
Your answer
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