PENNFIELD HIGH SCHOOL BAND

Student Information
Student Name_________________________ Date of Birth____________
Parent(s) or Guardian(s)________________________________________
Address___________________________ Cell Phone_________________
Home Phone___________________ Work Phone_____________________
Additional Emergency Contact____________________________________
Phone ________________ Relationship to Student _________________
Insurance Information and Consent for Medical Treatment
Name of Insurance Company ____________________________________
Policy Number _________________________ Group Number__________
Expiration Date of Policy ______________
I authorize Blake L. Driver and Charles Dixon, Directors of the
Pennfield High School Band, to take such necessary measures as
they deem appropriate in an emergency situation regarding the
health of my child. I further consent to any routine or other nonsurgical care that my child may be required to undergo during the
course of the Pennfield High School band camp.
Parent Signature ________________________ Date __________

(PLEASE CONTINUE TO OTHER SIDE OF THIS FORM)

Pennfield High School Band Camp

Rules and Policy Acknowledgement

(Parent and Student Signatures Required Below)

I have read and understand the rules and policies specified in the 2013
Band Camp Rules and Information sheet. I further understand that my
student will be expected to follow the rules and policies that it contains.
Parent Signature _________________________

Date ________

I have read and understand the rules and policies specified in the 2013
Band Camp Rules and Information sheet. I further understand that I will be
expected to follow the rules and policies that it contains.
Student Signature ________________________

Date ________