Microsoft word - reg form 2012_2013.docx

2012-2013 COLLINS HILL HIGH SCHOOL BAND PROGRAM
REGISTRATION FORM
STUDENT GENERAL INFORMATION
PARENT/GUARDIAN INFORMATION
EMERGENCY CONTACT
MEDICAL CONTACT INFORMATION
PLEASE PROVIDE A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD
**SEE MEDICAL SIGNATURE SECTION IF NO MEDICAL INSURANCE
2012-2013 COLLINS HILL HIGH SCHOOL BAND PROGRAM
REGISTRATION FORM
STUDENT MEDICAL INFORMATION
Is your student allergic to anything? (CIRCLE ONE) YES NO Does your student have any dietary restrictions? ( CIRCLE ONE) YES NO List any medications your student is currently taking and will bring to camp or on trips: Please check if any of the below medication may be dispensed to your student: Advil / Motrin (ibuprofen) ____YES ____ NO Explain any other medical conditions or circumstances we should be aware of and how they should be handled if a family member or emergency contact cannot be reached: 2012-2013 COLLINS HILL HIGH SCHOOL BAND PROGRAM
REGISTRATION FORM
PARENT VOLUNTEER OPPORTUNITIES (CHOOSE 3)
PLACE A “1” NEXT TO YOUR FIRST CHOICE, A “2” NEXT TO YOUR SECOND CHOICE AND A “3” NEXT TO
YOUR THIRD CHOICE
***NOTE – We will do our best to accommodate your choices. However, there are no guarantees. Due to the large amount of manpower required to run some of these events, you may be called upon to help with events you did not choose. For more information, see a volunteer at one of the volunteer tables
_______    TASTE OF COLLINS HILL (Feb. 2013)  _______    EAGLE’S NEST INVITATIONAL (10/20/12)  _______    PINE STRAW DELIVERY (Spring 2013)  _______    CHAPERONE (Various Events, Yearlong)  _______    COMMUNITY FUN DAY (Fall 2012)  _______    ROADIES (Various Events, Yearlong)  _______    FOOTBALL CONCESSIONS (Fall 2012)  _______    BAND CAMP (July 2012)                      AFTER SCHOOL   _______    CLERICAL TASKS (Yearlong)  _______    REHEARSALS (Summer/Fall 2012)  _______    HOSPITALITY (Various Events, Yearlong)  OPTIONAL – PLEASE INDICATE BELOW IF YOU ARE INTERESTED IN EITHER OF THE VACANT
BOARD POSITIONS
DONATED ITEMS (PLACE 2 STICKERS HERE)
2012-2013 COLLINS HILL HIGH SCHOOL BAND PROGRAM
REGISTRATION FORM
PARENT/GUARDIAN SIGNATURE SECTION
FINANCIAL
I hereby acknowledge receipt of the financial obligation policy. By signing here I agree to abide by the policy and meet the financial commitments therein. MEDIA RELEASE

Collins Hill High School may develop, participate in, or be the subject of media-based presentations and events which highlight various
educational activities that take place during the course of the school year. These presentations/events may include photographs, slide
presentations, video and other media containing images of your child. These may be used in programs, on the website, newspaper
articles and other Collins Hill approved media activities.
I hereby GIVE my permission to publish my child’s photograph and identification in as well as to publish my child’s presentation (as
listed above) in any of Collins Hill’s or Gwinnett County Public School’s media-based productions for the above stated purposes. BY
NOT SIGNING HERE YOU DENY PERMISSION FOR USE AS LISTED ABOVE

MEDICAL RELEASE
I hereby grant authorization to Band Directors, chaperones of Collins Hill High School Band Booster Association, standing in loco parentis, to obtain emergency medical and/or surgical treatment and procedures from a physician or hospital emergency room on behalf of the above named minor. I also give permission to administer over-the-counter medications if necessary. IF NO INSURANCE - FOR AND IN CONSIDERATION OF EMERGENCY SERVICES AND GOODS RENDERED BY OR THROUGH THE ATTENDING PHYSICIAN(S) THE UNDERSIGNED GUARANTEES PAYMENT IN FULL, IMMEDIATELY UPON RECEIPT OF FINAL BILLING.

Source: http://www.chhsband.org/Documents/Reg%20Form%202012_2013.pdf