Groove, Inc.
Member Registration 2016-17
______
Student Name______Age______Grade______
School______Instrument______
Years of: Percussion Experience______Groove Experience______Groove Group:______
_____ Check here if interested in learning more about scholarship opportunities for dues.
Father/Guardian Information (Print Clearly)
Name:______
Address:______
City, State, Zip:______
Home Phone:______
Employer: ______
Work Phone:______Cell Phone______
E-mail:______
Mother/Guardian Information (Print Clearly)
Name:______
Address:______
City, State, Zip:______
Home Phone:______
Employer:______
Work Phone:______Cell Phone______
E-mail:______
Please read the following and sign below:
I, the parent/legal guardian of the named registrant, a minor, agree that I will abide by the rules established by Groove, Inc. Recognizing the possibility of physical injury associated with participating in Groove, Inc. and in consideration of Groove, Inc. acting as the registrant for its drumline programs and activities (the “Programs”), I hereby release, discharge, and/or otherwise indemnify Groove, Inc., its instructors and associated personnel, including owners of the facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the programs and/or being transported to or from the same.
By signing this form, I agree and consent that Groove, Inc. has my permission to use any image, photograph, video clip, or other similar image, in any media format, of either myself or my child, provided (1) the image is taken while I am, (or my child is) a participant in one of the various activities, events, and competitions sponsored by Groove, Inc. or as otherwise allowed by law, and (2) the image is used for one or more of the following purposes: media coverage of Groove activities, Groove Website use, Groove promotional materials, program books, video presentations and for similar purposes related to the activities of Groove, Inc. I further release Groove, Inc. from any liability for any adverse results which may result from the use of the above named photograph(s) or media images in the manner described. To opt out check here ______.
I do agree that any email address I provide may be used by Groove, Inc. and any of their assigns to provide me with information about their programs. To opt out check here ______.
I certify that everything on this application is correct, to the best of my knowledge.
Signature of Parent/Guardian______Date______
Groove, Inc.
Permission for Emergency Care & Student Health Form (2016-17)
Student Name: ______Date of Birth: ______
Emergency Contact: ______Relationship: ______Phone:______
Insurance Company under which student is covered:______Phone: .______
Name of Insured: ______Policy #: ______Group #: ______
Does your insurance require precertification? Y N Phone # for precertification if different from above: ______
Name of student's physician: ______Phone: ______
Hospital Preference:______
Is the student allergic to any medications? If so, please list: ______
Is the student under physician's care for health needs on a continuing basis? Y N
Is the student under medication or treatment on a continuing basis? Y N
If yes to either of above, please explain and list all medications currently being taken and dosage schedule:
______
Is the student allowed to self-administer the medication? Yes No
Food allergies:______
Does the student require a special diet or prefer vegetarian? ______
Date of last tetanus shot: ______
I GIVE CHAPERONES or GROOVE PERSONNEL PERMISSION TO ADMINISTER THE FOLLOWING OVER THE COUNTER MEDICATIONS IF NECESSARY: (Please give permission for all medications which are not problematical to your child; otherwise we can't administer any medications that haven't been checked on this form without contacting you.)
Advil: ___Tylenol:___ Benadryl: ___ Imodium: ____Sinus/Cold meds: _____Pepto Bismol: _____Imitrol: _____
Bonine (for motion sickness): ____Midol:____ Other (please list):______
I GIVE CHAPERONES or GROOVE PERSONNEL MY PERMISSION TO CALL MY CHILD'S PHYSICIAN OR ANOTHER PHYSICIAN IN AN EMERGENCY WHEN MY CHILD'S PHYSICIAN OR I CANNOT BE CONTACTED. THEY ALSO HAVE MY PERMISSION, IN AN EMERGENCY WHEN I (OR MY CHILD'S PHYSICIAN) CANNOT BE CONTACTED, TO TAKE MY CHILD TO THE EMERGENCY ROOM OF THE NEAREST HOSPITAL. THIS HOSPITAL AND ITS MEDICAL STAFF HAVE MY AUTHORIZATION TO PROVIDE TREATMENT THAT A PHYSICIAN DEEMS NECESSARY FOR THE WELL-BEING OF MY CHILD.
Signature of Parent/Guardian ______Date ______
If there is additional information you feel would be helpful to share with us, please provide it here. Thank you!