PVM Band Student Information 2016-2017
Student Information (Please Print Clearly)
Student’s Name______Instrument______
Band Class/Period______
Student Information
Mailing Address: ______City and Zip Code:______
Home Phone Number:______Student Cell Phone: ______
Lives with:______Date of Birth:______
THIS WILL BE FILLED IN DURING CLASS:
Instrument Make/Model: ______Instrument Serial Number: ______
Parent/Guardian Information
Parent/Guardian #1: ______
Work Phone:______
Phone: (work) ______
Home Phone: ______
Cell Phone: ______
E-mail:______
I can best be reached at:work/home/cell/email
Parent/Guardian #2: ______
Work Phone: ______
Phone: (work) ______
Home Phone: ______
Cell Phone: ______
E-mail:______
I can best be reached at:work/home/cell/email
IN ORDER TO HELP BY CHAPERONING YOU MUST HAVE A CRIMINAL BACKGROUND CHECK ON FILE WITH OUR SCHOOL DISTRICT. PLEASE CHECK THE WEBSITE.
______
INTERNET PUBLICATION RELEASE
The Prairie Vista Middle School Band posts details and photos of our band events on our website: Band Facebook/Instagram. In order for your child to be pictured on the website, permission must be given by the legal parent/guardian. Please fill out the following form in order to provide permission to include your child on our website.
General Policies: Students names will never be associated with their photos. Full names will never be placed on the website (we will use First name, Last initial). We try to display group photos and try not to use individual photos. Your child’s safety is our highest priority. We would never do anything to intentionally put your child in harm’s way.
Student Name: ______
____I GIVE PERMISSION for the band directors at PVMS to use band photos in which my child is pictured.
____ I DO NOT GIVE PERMISSION for the band directors at PVMS to use band photos in which my child is pictured on the website or Facebook/Instagram. My child’s likeness* and name should not appear online or be published in any way. (*in this case, your child’s likeness in group photos will be blurred)
Parent/Guardian Signature: ______
FIELD TRIP PERMISSION AND AUTHORIZATION
FOR EMERGENCY CARE TO MINOR
As parent/guardian of ______, I give my permission to the Eagle MountainIndependentSchool Districtfor the student indicated to participate with his/her band class on field trips throughout the 2016-2017 school years. Parents will be notified in advance of changes and/or additional field trips. Staff members will accompany the children. He/She will leave the middle school band hall by bus at a predetermined time.
In the event of a medical emergency (in the judgment of school personnel) to the minor student during the trip, I/We hereby authorize ambulance transport, X-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any ambulance service, physician, dentist, or hospital services or any other emergency medical services to said minor whether such diagnosis or treatment is rendered at the office of the physician, dentist or hospital.
It is understood that this consent is given in advance of any specific diagnosis or treatment being required, and is given to encourage the band staff who have temporary custody of the minor, and said physician or dentist to exercise the best medical judgment in diagnosis, medical, dental or surgical treatment. I/We understand that I/We will assume full financial responsibility for care rendered. I/We release Eagle MountainIndependentSchool Districtfrom all liability in case of an accident.
Signature ______Date______
(Parent/Legal Guardian or Person Responsible for Student’s Care)
Signature ______Date ______
(Parent/Legal Guardian or Person Responsible for Student’s Care)
Insurance Company Name:
Insurance Company Phone #: Group #:
Please list any allergies or other special medical conditions, ie diabetic, asthma-carry own inhaler: ______
In case of an emergency please call:
Name: ______Phone #: ______
Relation to Student: ______
______MY STUDENT HAS A CONDITION THAT REQUIRES AN EPIPEN!