Decatur High School Marching Band
2017-2018 Registration Form
Registration Information
Last Name
Your answer
First Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Graduation Year
Your answer
Marching Instrument
Your answer
Concert Instrument
Your answer
Check one of the following:
Band camp T-shirt size.
Food options for band camp
Contact Information
Student Contact Information
Student's Primary Address
Street
Your answer
City
Your answer
State
Your answer
ZIP
Your answer
Primary Phone for Primary Household
Your answer
Type of number
Student Cell Phone
Your answer
Student Email Address
(whatever address is checked frequently)
Your answer
Parent/Guardian #1 Information
Parent/Guardian #1 Name (Primary Household)
Your answer
Parent #1 Address (if different from Student's Primary Address)
Your answer
Home Phone (only if landline)
Leave blank if you use a cell phone as a home phone.
Your answer
Parent #1 Cell Phone
Your answer
Parent #1 Work Phone
Your answer
Parent #1 Email Address
Your answer
Parent/Guardian #2 Information
Parent/Guardian #2 Name
Your answer
Parent/Guardian #2 Address (if different from Student's Primary Address)
Your answer
Home Phone (only if landline)
Leave blank if you use a cell phone as a home phone.
Your answer
Parent #2 Cell Phone
Your answer
Parent #2 Work Phone
Your answer
Parent #2 Email Address
Your answer
Releases and Consents
Directory Release
Release the above information to the 2017-2018 band directory.
By entering your initials in the box below, you are effectively providing your signature, indicating that you have the right to release this information
Your answer
Photo Release
Release for DHSBPA to display photographs, video images, or audio clips in DHS publications of my child,
student's name
Your answer
Please check one box below for photo release
Please initial. By entering your initials in the box below, you are effectively providing your signature, indicating that you have the right to consent for this student.
Your answer
Field Trip Consent
I hereby consent for
student's name
Your answer
to participate in athletic team; band, orchestra, chorus, and/or any other sponsored field trips during the 2017-2018 school year. I understand that transportation may or may not be provided by the City Schools of Decatur. In the event transportation is not provided by the City Schools of Decatur, transportation will be the student's responsibility.
Please initial. By entering your initials in the box below, you are effectively providing your signature, indicating that you have the right to consent for this student.
Your answer
Date of Consent for Field Trips
MM
/
DD
/
YYYY
Consent for Medical Treatment
I, the undersigned, being the parent or legal guardian of
student's name
Your answer
born on
student's date of birth
MM
/
DD
/
YYYY
hereby grant authorization to the Band Director or any chaperone of the Decatur High School Band Parents Association (DHSBPA), standing in loco parentis, to obtain any emergency medical and/or surgical treatment procedures from a physician or hospital emergency room physician on behalf of the above-named minor. I also authorize the release of this student after receiving emergency treatment to the Band Director or any chaperone of the DHSBPA
Please initial. By entering your initials in the box below, you are effectively providing your signature, indicating that you have the right to consent for this student.
Your answer
Date of Consent for Medical Treatment
MM
/
DD
/
YYYY
Waiver and Release
I release and waive, and further agree to indemnify, hold harmless or reimburse the City Schools of Decatur, the individual members, agents, employees and representatives therof, as well as trip supervisors, from and against any claim which I, any other parent of guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, from any losses, damages, or injuries arising out of, during, or in connection with the student's participation in the activity, any trip associated with the activity, or the rendering of emergency medical procedures or treatment.
Please initial. By entering your initials in the box below, you are effectively providing your signature, indicating that you have the right to consent for this student.
Your answer
Date of Waiver and Release
MM
/
DD
/
YYYY
Emergency Information
Insurance Information
Insurance Company
Your answer
Group Number
Your answer
Insurance Policy Number
Your answer
Insurance Phone
Your answer
Physician Information
Primary Care Physician Name
Your answer
Primary Care Physician Number
Your answer
Payment Guarantee
For and in consideration for emergency services and goods rendered by or through the attending physicians(s), the undersigned guarantees payment in full, immediately upon receipt of final billing.
Please initial. By entering your initials in the box below, you are effectively providing your signature, indicating that you have the right to consent for this student.
Your answer
Date of guarantee
MM
/
DD
/
YYYY
Emergency Contacts
Please provide 2 emergency contacts that are not household members. Do not relist parents or guardians from the contact information section. These emergency contacts will only be used if we are unable to reach parents/guardians at all of the given contact numbers (cell, home and work).
Emergency Contact #1 (not a parent or guardian)
name
Your answer
relationship
Your answer
phone number
Your answer
Emergency Contact #2 (not a parent or guardian)
name
Your answer
relationship
Your answer
phone number
Your answer
Medical Information
For the safety of your student, this information will be made available to teachers and chaperones.
Please list all known allergies including medications, food, animals, insect bites/stings and environmental allergens with reaction and required treatment.
Write NONE if this doesn't apply to your student.
Your answer
Please list any health conditions that could impact your student's participation and provide a brief explanation.
Write NONE if this doesn't apply to your student.
Your answer
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