STUDENT INFORMATION

Name: ___________________________________________________________________ Last Middle FirstInstrument:________________________________________________________________ Type Make Model Serial NumberE-mail Address:____________________________________________________________

Used to relay information about the LHS Band ONLY

T-Shirt Size ____ Small ____ Medium ____ Large ____ X-Large ____ XX-Large

PARENT/GUARDIAN INFORMATION

Father/Guardian:___________________________________________________________ Last Middle FirstMother/Guardian: __________________________________________________________ Last Middle FirstE-mail Address:____________________________________________________________

Used to relay information about the LHS Band ONLY

MEDICAL INFORMATION

FORM CFILE: IFCBFILE COPY

HARRISON COUNTY BOARD OF EDUCATIONEMERGENCY MEDICAL TREATMENT

APPLICANT'S NAME:______________________________________________________ Last Middle FirstADDRESS:________________________________________________________________ TELEPHONE NUMBERS(____)________________(____)____________________(____)______________________ (HOME) (Father-Bus.) (Mother-Bus.)Is he/she allergic to any medicine or drug? ____ If so, please explain: __________________________________________________________________________ Has he/she had tetanus shots? _________ When: ______________ Blood Type:__________ Family Physician: ________________________________ Religion: ___________________ Instructions for emergency medical treatment: _____________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Medicines being taken: ________________________________________________________ Insurance Company:___________________________________I.D.#___________________ FOR THE PARENT OR GUARDIAN:

I hereby grant permission for the above applicant to participate in extra-curricular activity. In the event of accident or medical illness, permission isgranted for any such medical and/or surgical treatment as may be necessary.Every effort will be made to notify me before any major treatment isundertaken. _________________________________ Signature of Parent or Guardian