SPHS Choir Student Contact Information & Medical Consent Form
This form must be completed by all SPHS Choir students AND parents. Typed names on this document will serve as signed consent from both the student AND the parent.
Email address *
Student ID Number
Your answer
Student Last Name
Your answer
Student First and Middle Name
Your answer
Parent/Guardian #1 Name (First & Last)
Your answer
Parent/Guardian #1 Phone #
Your answer
Parent/Guardian #1 Email Address
Your answer
Parent/Guardian #2 Name (First & Last)
Your answer
Parent/Guardian #2 Phone #
Your answer
Parent/Guardian #2 Email Address
Your answer
Address
Your answer
Zip Code
Your answer
Student Cell Phone Number
Your answer
Student Email Address
Your answer
Current Grade
Birthdate
MM
/
DD
/
YYYY
T-Shirt Size (adult sizes)
In which choirs are you enrolled?
Emergency Contact Name (First & Last)
Your answer
Emergency Contact Relationship
Your answer
Emergency Contact Primary Phone #
Your answer
Emergency Contact Secondary Phone # (if applicable)
Your answer
Emergency Contact Address
Your answer
Emergency Contact Zip Code
Your answer
Emergency Contact Email Address
Your answer
Does your student have any medical conditions or is he/she under any medication?
If yes, please explain:
Your answer
Please list any allergies:
Your answer
Insurance Policy Holder Name
Your answer
Insurance Company
Your answer
Insurance Policy Number
Your answer
Insurance Group Number
Your answer
Insurance Company Phone #
Your answer
Insurance Address
Your answer
Doctor's Name
Your answer
Doctor's Phone #
Your answer
In the event I cannot be reached in an emergency, I give permission to the Choir Directors and/or authorized personnel to secure the proper treatment for my student. (Please type Parent/Guardian #1's Name & Relationship)
Your answer
In the event I cannot be reached in an emergency, I give permission to the Choir Directors and/or authorized personnel to secure the proper treatment for my student. (Please type Parent/Guardian #2's Name & Relationship)
Your answer
A copy of your responses will be emailed to the address you provided.
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