Cupertino High School PROUD Pioneer Marching Band

Welcome to the 2021 – 2022 Season!

Dear Returning & New Members of the Cupertino High School PROUD Pioneer Marching Band,

This is the registration packet to be completed and turned in at the MANDATORY August registration:
(Students and Parents must attend this registration. Please see below for your registration time.)

Mandatory Registration | Saturday, July 31st, 2021

Cupertino High School Band Room

9:00 am Returning Woodwind Check-in

10:00 am Returning Brass Check-in

10:30 am Returning Percussion & Color Guard Check-in

11:00 am Freshman/New Member Check in (Last Name A-M)

11:30 am Freshman/New Member Check in (Last Name N-Z)

We look forward to meeting each and every one of you! Please use the checklist below to assist you in
completing this packet.

◻Family Information, Student and Parent Information: Every students needs to complete both pages.
◻Zero Tolerance Form: Every student must complete this form.
◻Instrument Insurance: Every student must complete this form.
◻Food Planning Questionnaire: Every student must complete this form.
◻eScrip Signup: Please complete to participate in this program.
◻AmazonSmile: Please sign up!
◻Company Match: Please use your company’s match program to support the band.
◻Contribution Worksheet: Complete student’s name at the top and bring to registration with payment.
◻School Physical Exam Form, Part 1 and 2: This MUST be completed and signed by a doctor for the
student to participate in the band program. Both pages MUST be turned in at registration.
◻School Field Trip Form: Every student must complete this form.

Parents, please join us for our Parent Orientation and learn about what to expect this year in band:
Parent Orientation | Monday, August 2, 2021 at 8:00 pm in the Band Room
More info at www.chsmarchingband.org
Connect on Facebook: Cupertino High School Marching Band and Color Guard 2021-22

Please feel free to contact me if you have any questions.

Gilbert Iruegas (‘Mr. I’) gilbert_iruegas@fuhsd.org (408) 366-7395
Band Director, Cupertino High School PROUD Pioneer Band
 Cupertino High School Marching Band & Color Guard
Family Information
[Please Print Neatly In Ink]

Student Information

Student Name: Last ______________________ First ______________________

Grade in 2021-22 School Year: _________ Gender: __________________

Instrument (Circle one):

Flute Piccolo Clarinet Bass Clarinet

Alto Saxophone Tenor Saxophone Baritone Saxophone
Trumpet French Horn (Mellophone) Trombone Baritone
Tuba Drumline Front Ensemble Color Guard
Other: _____________
How long have you been playing your instrument? _____________________
Student Address: ______________________ City_________ Zip Code________
Student Cell Phone Number: (_______) _______ - _________
Can we text you? (Circle one) Yes No
Student Email Address: _________________________@___________.______
Main language spoken at home: _________________________________

We use email as our primary means of communication.

Please fill out this form carefully to make sure we have accurate email
addresses at all times.

Page 1
Parent Information: Parent 1

Last Name: _________________________ First Name:____________________

Gender: __________________
Home Phone: (_______) _______ - _________
Cell Phone: (_______) _______ - _________
Email Address: _________________________@___________.______
Can we text you? (Circle one) Yes No
Available to help: Daytime:________ Evenings:________ Weekends:________
Do you have Marching Band Experience? _______________________________
Special Skills: _____________________________________________________
(Sewing, Carpentry, Artist, Medical Training, CERT, Electrical, Events, Catering, etc.)

Parent Information: Parent 2

Last Name: _________________________ First Name:____________________

Gender: __________________
Home Phone: (_______) _______ - _________
Cell Phone: (_______) _______ - _________
Email Address: _________________________@___________.______
Can we text you? (Circle one) Yes No
Available to help: Daytime:________ Evenings:________ Weekends:________
Do you have Marching Band Experience? _______________________________
Special Skills: _____________________________________________________
(Sewing, Carpentry, Artist, Medical Training, CERT, Electrical, Events, Catering, etc.)

Page 2
 Cupertino High School Marching Band & Color Guard
Code of Conduct

Zero Tolerance

Clause 1: In a proactive effort to keep our students healthy and out of trouble, we are
encouraging them to make the “right” decisions regarding the use of alcohol and illegal
drugs. The Cupertino HS Proud Pioneer Band has a zero tolerance policy which states
that anyone who partakes in illegal activity, including being in possession or under the
influence of alcohol or illegal drugs, in or out of school, will be removed from the band
program immediately.

Clause 2: The Cupertino HS Proud Pioneer Band also has a zero tolerance policy for all
forms of bullying, including cyberbullying. In order to create a family-like environment
based on mutual respect, we will take action to ensure that members are following this
policy. Members are expected to hold themselves and their peers accountable for their
actions, and report to Mr. I, their Section Leaders, or Drum Majors if any occurrences of
bullying arise. Those who infringe upon this policy will face consequences.

Please sign below to confirm that you have read the statements above and will abide by
the Cupertino HS Proud Pioneer Band Zero Tolerance policies.

Student Name ___________________________________________________________

Student Signature _______________________________ Date ___________________

Parent Name ___________________________________________________________

Parent Signature _______________________________ Date ____________________

Page 3
 Cupertino High School Marching Band & Color Guard
Instrument Insurance

Cupertino High School and its staff make every effort to ensure the security of equipment
at each of our events and at our school facilities. Occasionally, equipment or instruments
are damaged or go missing. The expense of replacing equipment can be quite a burden. In
many cases, the instrument can be replaced through your homeowner or renter insurance.
Please check with your insurance agent to be sure.

If you do not have insurance that can help you replace your missing or damaged
instrument, you can purchase insurance designed especially for musical instruments. This
can be purchased from Clarion Musical Instrument Insurance. To apply for this insurance
please call the company directly at 1-800-848-2534 or go to their website at
www.clarionins.com. The cost of the insurance depends upon the value of the instrument.

This insurance is for personal instruments. School-owned instruments do not need to be

insured as they are covered by the school.

Check the appropriate statement.

________ I am using a school-owned instrument so insurance is unnecessary.
________ I will insure the instrument through the Clarion Musical instrument Insurance.
________ I do not wish to insure the instrument.
________ I have instrument insurance and will not need to get additional insurance.

All, please complete this portion regardless of the insurance option chosen.

Student Name: ___________________________________________________________

Instrument: ______________________________________________________________
Serial Number: ___________________________________________________________
Insurance Company: ______________________________________________________
Policy Number: __________________________________________________________
Parent Signature: _________________________________________________________
Date: __________________________________________________________________

Page 4
 Cupertino High School Marching Band & Color Guard
Food Planning Questionnaire
Vegetarian options are always available. Other dietary restrictions can usually be accommodated. With the exception
of pepperoni pizza (which will be clearly marked), we will not serve any pork products. In addition, we will not
serve any seafood products.

Allergies
Yes No I have food allergies.*
Yes No I carry medication (Benadryl, EpiPen, etc.) for my food allergy.
*(Allergies are a physiological reaction, NOT just a strong dislike).

List ALL food allergies.

_____________________________________________________________________________

Restrictions (Circle all that apply):

Yes No I can eat anything, no restrictions.
Yes No I am completely lactose intolerant (unable to digest dairy at all).
Yes No I am vegetarian, but not vegan (eggs & dairy products are acceptable).
Yes No I am vegan (no animal products at all).
Yes No I require gluten-free food.
Yes No I am diabetic and need to control my blood sugar level.

I will eat the following foods:

Yes No Poultry
Yes No Beef
Yes No Dairy products (milk, cheese, ice cream, etc.)

◻ Please check here if you plan to bring your own food and you do not plan to eat the food provided.

Anything else we should know about your dietary needs? ______________________________

Student Name: _________________________________________________________________

Student Signature: ______________________________________________________________
Parent or Guardian Name: ________________________________________________________
Parent or Guardian signature: _____________________________________________________
Parent or Guardian 1 Cell Phone #: (__________) __________ - _____________
Parent or Guardian 2 Cell Phone #: (__________) __________ - _____________
◻ Please check here to allow the Food Coordinator to contact you. Please provide the best contact
numbers for the parent(s) and student so the Food Coordinator may contact you with questions.
 A
Making the Grade...
+
is an important part of our fundraising
program. We ask that every family help us
make the grade in our fundraising goal.

Our school needs your support!

We need all of our families to get straight A’s in

their enthusiasm to raise funds. This task will not
require hours of homework but just a few minutes
of your time and your grocery club card number.

Log onto www.eScrip.com. Enter the School or Group I.D.

Group:CHS Marching Band or ID #150733830

You can also register your debit and credit cards.

Shop at eScrip merchants!

Use your eScrip registered cards for all your purchases.

A percentage of purchases will be automatically contributed

by the merchant.

That’s it! It’s that easy----your family shops--- our

school earns dollars.

For eScrip Program Information, Merchant Lists or to sign up online visit www.escrip.com
Electronic Scrip Incorporated (ESI) has made a firm commitment to protect all customer information provided. ESI will not license, sell, exchange or distribute any personally
identifying information about eScrip participants to any third parties not directly involved with the eScrip program. Visit www.escrip.com for complete Terms and Conditions.
 M B
M M

Cupertino High School Band Boosters is a 501(c)(3) non-profit organization

oe our co pan atch o unteer hour or donation

o unteer our

Microsoft, AMD, Spansion, Intel and Adobe may match your band volunteer hours with a monetary donation to
Boosters.

This may range from $10-17 per hour, which adds up quickly!

Please check if YOUR company will match the volunteer hours you provided at Tournament of Bands!

onation

Also, many corporations will match all or a portion of their employees monetary donations.

It is possible that your band contribution may apply. It all depends on your individual company’s guidelines.

Please take a moment to check your company’s program!

The five minutes it takes to fill out the form may benefit the Cupertino High School Band Boosters!

Here is a list of some of the companies that will match all or a portion of their employees’ monetary donations. (If
you know of any additions or errors to this list, please let us know):

Abbott Laboratories LAM Research

Adaptec, Inc. Loral
Advanced Micro Devices Macromedia
Adobe Systems, Inc. McAfee
Allied Signal Inc. Mentor Graphics
ALZA Corporation Microsoft
American Express Morgan Stanley
Analog Devices Motorola
Applied Materials, Inc. National Semiconductor
Applied Signal Technology Network Associates
Aspect Nokia
AutoDesk Northorp
Page 7
 Bank of America Pequot Capital Management, Inc.
BEA Systems Pfizer
Beckman Coulter Oracle
Boeing Qualcomm
Cadence Design Systems Rambus
Cisco Systems, Inc. Robert Half International
Citibank Rockwell Collins
Citigroup SAP
Computer Associates Shaklee Corp.
Dain Rauscher Silicon Graphics
DataProse Sony USA
DavidLucile Packard Foundation Spansion, Inc
Deutsche Bank Sun Microsystems
Electronic Arts Symantec
FundGuidant Synopsys
GAP Tencor
Genentech Tyco
Greater Bay Bancorp UBC Realty Investors
Google Varian
Grumman Veritas
H.B.FullerQuantum Corporation Verity
Home Depot Verizon
HoneywellRBC Warburg Pincus Foundation
Intel Washington Mutual
Intuit Wells Fargo
JDS Uniphase eBay Foundation
Johnson Johnson Northwestern Mutual
Juniper Networks Xilinx, Inc.
Kidder, Peabody Co., Inc. Yahoo
KLA
Knight Ridder, Inc

Our Federal Tax ID Number is available on request.

Please contact the Treasurer (treasurer@chsmarchingband.org) for the number or with any questions.

Thank you for your continued support of the Cupertino High School Proud Pioneer Marching Band!

CHS Band Boosters

Page 8
 M B
M M

Cupertino High School Band Boosters is a member of AmazonSmile!

If you are an Amazon customer, this service lets you make a gift towards your favorite
non-profit organization with your purchases – without spending an extra dime.

To sign up, visit this link:

http://smile.amazon.com/ch/56-2349318

You will log into your Amazon account and choose Cupertino High School Band
Boosters as the organization you will be supporting.

You will be able to see which items qualify for a donation. When you check out, Amazon
will send a portion of the regular print of your qualifying purchases to CHS Band
Boosters.

We hope that this service makes it even easier for you to consider supporting the band!

Thank you!

Page 9
 Cupertino High School Marching Band & Color Guard
2021-2022 Contribution

Student Last Name: ___________________ First Name: ___________________

The contribution for the 2021-22 school year is $1,000 per student.

This contribution is necessary in order to fund the Marching Band program and
provide our students the best educational and musical experience possible.

Provided through this contribution amount are:

● All competition entry fees
● Transportation to all events via Royal Coach Charter bus
● Meals while on trips
● Musical Arrangements
● Marching Band Drill
● Instruction by extremely experienced and passionate staff in the Bay Area
● Instrument Use
● Equipment Use
● Uniform Usage

Other amounts that may be due:

● Marching Band Shoes ($45)
● Color Guard Shoes ($38)
● Extra Band Shirts for parents or students ($13)

Please make checks payable to: CHS Band Boosters

Total Amount Paid: ____________________

Corporate Match ( Yes / No ) Company Name: _________________________
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 Fremont Union High School District
589 West Fremont Ave., Sunnyvale, CA 94087 408-522-2200

PARENT/GUARDIAN FIELD TRIP PERMISSION AND MEDICAL AUTHORIZATION (Minor)

District-Sponsored Event
(Attendance Voluntary)

___________________________________ has my permission to go on the following voluntary field trip:

Student’s Name

Destination: Various dates: Oct. 2 - Nov. 20, 2021

Date(s): _______________________ Departure Time: TBA Return Time: TBA
Person In Charge: Gilbert Iruegas
Health Needs: Initial and complete as appropriate.
___________ My student has NO special health needs that staff should be aware of, and NO
aaaaaaaaaaaaaaaaaaaaaamedication is required on the trip.
___________ My student has a special health need. ___________________________________
aaaaaaaaaaaaaaaaaaaaaaand the following medication should be given to the person in charge along with
aaaaaaaaaaaaaaaaaaaaaawritten instructions form the students attending physician:
_____________________________________________________________________________________

In the event of illness or injury, I do hereby consent that whatever x-ray examination, anesthetic, medical, surgial, or
dental diagnosis or treatment and hospital care are considered necessary in the best judgement of the attending
physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the
hospital or facility furnishing medical or dental services.

As stated in California Education Code Section 35330, I understand that I hold the Fremont Union High School
District, its officers, agents, and employees, harmless from any and all liability or claims, which may arise out of, or
occur, in connection with my students participation in this activity.

I also understand and am fully aware that there may be periods of time during this activity in which my
student has free time and is unsupervised, and that the District assumes no responsibility for the students
activities or behavior during this free time. I fully understand that participants are to abide by all rules and
regulations governing conduct during the trip. Any violation of these rules and regulations may result in that
individual being sent home at his/her/their and/or parents’ expense and possible suspension or expulsion from
school. It is further understood that the above-named student may travel by automobiles operated by District
employees, adult volunteers, or other licensed drivers, including students.

As parents/guardians of the above-named student, it is realized that field trips have certain risks involved and that
reasonable attempts will be made to safeguard students and equipment, but that no amount of precaution taken by
the instructors can ensure this safety if the student does not obey and cooperate and is unable to accept the
responsibility for his/her/their own actions.

__________________________ __________ __________________________ __________

Parent/Guardian Signature Date Student Signature Date

_________________________________________ (________) ________ - ___________ ___________

Address Telephone Date

___________________________________________________ _________________________________
Family Health Insurance Carrier Policy Number

___________________________________________________________________________________________
Address City/State ZIp Code

MAIN LANGUAGE SPOKEN IN HOUSEHOLD: __________________________________________________

EMERGENCY CONTACT: _____________________________________________________________________

Name and Telephone

Distribution: White: School Site Yellow: Staff/Trip Pink: Parent/Guardian/Student

Form 6153.6 (Rev. 5/01, 8/05, 10/07) Field Trip Permission 6153.5 [5/09-5000]