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2019-2020 Tiger Marching Band

Information, Schedule and Attendance Policy

Pickerington Central Music Boosters:

We are an organization that supports our band through financial and volunteer needs. We need everyone’s help to make many of the things our band does possible. Below are links to our Facebook page and our website. Please utilize the website, Mr. Stowe will post his FYI there with important information. You will also find the calendar and many links to information.

Booster Website: http://pickeringtonmarchingtigers.org

Booster Facebook page: https://www.facebook.com/groups/pickeringtoncentralmusicboosters/

Band Camp:

For one week the entire band, including staff and volunteer staff, practice together in preparation for a successful year and is where the band prepares for the bulk of their performances at half-time shows. Successful performance is achieved through the contributions of each student with the goal of practicing the way the band performs throughout the year. Each student plays a very important role in the program and to practice effectively, student must be present for each rehearsal.

If any student is unable to attend, Nathan Stowe our band director must be contacted at nathan_stowe@plsd.us and / or an absence form must be submitted in advance.

Other Camps:

• Leadership Training – specific to selected upperclassmen

• Rookie Days – for all incoming freshmen and/or 1st year members (done in May)

• Pre-Camp – July 15-19, 2019, beginning at 8:00 am and ending at 11:30 am. This

camp is for all students in marching band and is designed to prepare students for

half-time shows as well as getting them familiar with school songs associated with

the Tiger Marching Band. If possible, there may be some marching.

• Color-Guard – Specific dates / times are handled under the direction of Ms. Allie

• Percussion – Specific dates / times are handled under the direction of Mr. Tim

Gorgas.

Band Camp Days: Sunday July 21, 2019 through Friday, July 26, 2019

• Some of these dates are subject to change. We unfortunately do not have control

over cancellations/weather. Events might be added or dropped as the season

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progresses. This is the starting point through the end of the summer. A fall calendar

with contest dates and games will be issued as football and contest schedules are

finalized.

Band Camp Attendance Policy:

• The student’s attendance is expected for all events during the week. The key is

COMMUNICATION. If you know of an absence in advance, please be sure to fill out

an absence form which is attached and give to the directors.

Band Camp Forms and Fees:

• Sunday July 21, 2019, registration day. Registration for all band students will begin at 12:30pm in the PHSC cafeteria and runs until 2pm. You are more than welcome to stagger arrival times to help keep lines flowing better.

• Forms: The attached forms must be completed for each band member. Please complete the forms prior to registration (RECOMMENDED) and bring the forms with you and our volunteer staff will ensure they get to the right person.

Attached FORMS:

Student / Parent Information Form – must be completed before your child can participate in band camp

Student Financial Hardship Form. We want to ensure that every student who

wants to participate in band can and do not want a financial hardship to

prevent any student from participation. Once we receive this form, it will be

forward this to our Band Director, Nathan Stowe. You may also contact him

at nathan_stowe@plsd.us

Non-Athletic Extracurricular Responsibility Acknowledgement Forms – must be completed before your child can participate in band camp.

Pickerington Central Marching Tigers Pre-Planned Absence Form must be completed and sent to the Director Nathan Stowe for any student who cannot participate in band camp or on any scheduled day. This is also the form used for any preplanned absence throughout the year.

Pickerington Student Emergency Medical Form. This Form must be completed before your child can participate in band camp.

Emergency Medical Authorization Form must be completed before your child can participate in band camp.

Forms that have a web address link available from the district website:

NOTE: All forms are either attached to this document or a link is inserted for your convenience.

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Financially Disadvantaged Student Fee Application

Volunteer Application Form - must be completed before a parent can chaperone. We encourage our volunteers to become level 2 approved. This requires a background check through the district.

● Charms: This is the database we use for student accounts. Each child will have (or has) a charms number specific to them. Parents can access the information on-line to see the fees paid, amounts due and track their fundraising credits. Our volunteers will be happy to assist you with obtaining a charms account and providing parents with information specific to their accounts.

• Booster Fee Payment:

Booster fees are used to cover expenses of our students that are not covered by the district. Some included band camp, awards, instruments, trailer registration and insurance, music, marching band show designs and other expenses.

Booster fee payments of $175.00 per student. The payment can be made by check

and/or cash with receipts given upon request. Fees are due by August 30, 2019

Checks should include the student name and “booster fee” in the memo portion of the check. Please DO NOT give money or checks to the band directors.

There will be a $25 returned check fee for any returned checks. If a family/person bounces two checks that form of payment will no longer be accepted. Payment will be required in the form of a bank check, cashier’s check, money order or cash.

FEES ARE DUE BY AUGUST 30, 2019

A copy of the PCMB 19/20 budget was sent out via email

Fees can also be mailed to: Pickerington Central Music Boosters (PCMB) P.O. Box 254, Pickerington, OH 43147 Attn: Booster Fee

NOTE:

NOTE: District Pay to Play fee:

The Booster fee is separate from the Pickerington Local School District pay-to-play fee which will be communicated to parents by the School District. The Pay-to-Play fee for the 2019-2020 season is $150.00.

Checks should be made payable to PLSD at 90 East Street, Pickerington, OH 43147

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Financial Hardship Support:

The Pickerington Central School District mandates that a payment exemption to booster fees be provided for families who are experiencing financial hardship and we will not turn any student away. If any fee presents a financial hardship, please contact one of our executive board staff members about payment arrangements. The form will be held in strict confidence for purposes of granting the exemption. Once we receive the form, we will forward it onto the director. You may also contact him at nathan_stowe@plsd.us

• Tiger Cards: Each band student is required to sell two (2) cards at the rate of $10.00 per card with payment being due at registration. Tiger cards payments can be made by cash or check made payable to the Pickerington Central Music Boosters (PCMB). Parents may purchase more than the minimum two (2) cards. After the two mandatory cards are sold, $5 credit for each additional card sold will be placed into the student’s Charms accounts.

• Uniform Fees: Each parent will be given information on the cost of uniform fees specific to their band student with payment being due at registration.

New parents please remember this fee is much higher the first year because your child will need all uniforms parts for both the summer and marching band uniforms along with shoes.

Uniform fee payments can be made by cash or check payable to the Pickerington Central Music Boosters (PCMB).

All fees are due before August 30. Payments are to be mailed to: Pickerington Central Music Boosters (PCMB) P.O. Box 254, Pickerington, OH 43147 Attn: Uniform Fee. Please include the band student name and “uniform fee” in the memo area of your check.

At band camp, you will be able to write 1 check for fees, tiger tigers etc.

• Spirit wear: We are still currently working on updating the spirit wear. You can purchase current items on the website but watch for more to come this fall. (if there are types of items you may be interested in, let us know and we can see about adding them to our list)

Band Camp Report Times: Attached is a band camp schedule for the entire week.

• Sunday, July 21, 2019 – after registration – all band kids must report to the band director Nathan Stowe at 2:00 pm at the band room. Band camp ends at 9:00 pm with pick up of students in the band field parking lot.

• July 22, 2019 through July 26, 2019: Kids should report to band camp each day at 7:45 am and be on the band field at 8:00 am.

• Band Camp ends at 9:00 pm July 22 through July 25, 2019 – See Attached Schedule

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• Friday, July 26, 2019, band camp ends around noon. However, there will be a group photo that is scheduled after lunch. Individual photos will be taken at a different date.

• Throughout the week, there will be other activities for students to participate in to include talent shows, dances and even a parent concert. Please ask your children each day at pickup to ensure you know alternate pickup times.

Water Bottle Donations:

• Water bottle cases: Our students go through a lot of water during band season and we are asking our band parents for donations. Water is distributed during parades, football games and at practice.

• We are asking that each child bring 2 cases of water at registration. Volunteers and leadership will provide curbside service at the PCHS main entrance (Commons side) beginning at 12:30 pm.

• Parents can drop off additional water bottle cases during the first day of band camp or throughout the week. We truly appreciate all your donations.

Food Breaks:

• Breakfast – please encourage your child to eat something for breakfast prior to arrival.

• Lunch – 1 Hour:

Students are not permitted to leave the premises.

Students should bring lunches with them at the start of the day.

Lunch bags, etc. should have each kid’s name clearly spelled out on the container

Lunches will be stored in our refrigerators and accessible during designated breaks

• Dinner – 3 Hour break – Students must leave the premises and there will not be adult supervision during this time:

Some of our parents host dinner for students based on their section. Students may need a ride and many times section leaders will reach out to provide transportation. Students will receive information about the hosting parent locations throughout the week. (reminder these are separate from the band and

Please remember to ask your child(ren) to bring their summer uniform for the group photo.

NOTE:

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are an optional event, the directors and boosters are not responsible for your child during this time)

There are plenty of upper classmates who help with transportation to off-site places for dinner (e.g. bw3, taco bell, etc.) Please remember state laws of teen age drivers and send students with money to pay for dinner. The average cost is about $10 - $12. This is an excellent way for our band kids to bond and meet those upper classmates. Students will receive information about restaurant meeting locations during band camp.

Activities Throughout the Week:

• Group Photo: Friday, July 26, 2019, around 1:00 pm. This photo is for the football program and will be in the summer uniform. We are working on arranging a time in the future for individual photos in the marching uniform.

• Costume day: Many of the sections will have custom day and will let their group know about the theme (e.g. super heroes, nerds, backward day, etc.)

• Miscellaneous events such as talent contests, parent concert, and other events will be communicated each day. Please ask your child(ren) when you pick them up at the end of the day because the mornings will be hectic and they may forget.

• Kona Ice will be back this year. The company will be setting up a truck for Pre-camp week (July 15-19), Monday through Friday beginning at 11am in the parking lot by the band field. P r i c e s a r e a p p r o x i m a t e l y small cup will be $3 and a large will be $6. Kona Ice will be giving back 25% of the profits to our band boosters. Please feel free to share this with everyone you know, the more the merrier!!

Miscellaneous Items:

• Encourage your child to eat breakfast and drink something in the morning

• Instruments and cases will be secured in the band room. Students may leave them at the end of the day in our secured location. Please make sure each instrument case is clearly marked.

• Comfortable clothing, tennis shoes and socks and hats (if desired). No halter tops, muscle shirts or bathing suit tops. Students should wear no other shoes than tennis shoes.

• Please make sure your child(ren) cell phone is charged. We have limited slots for this purpose

• Sunscreen is critical. Please make sure your child uses sunscreen before leaving in the morning and pack this in their bookbag so they reapply throughout the day.

• Water jugs. Each child should bring a water jug during practice. Hydration is critical and we will have some breaks throughout the day for kids to refill those water jugs. Include their names on the jugs and fill them with ice.

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• Sunglasses

• Bug spray is important because they will be in the grass throughout the day and no matter how low the grass is those flying critters will find your kid.

• If students have previous knee/ankle injuries - please bring your own ace bandage

or wrap to rehearsals.

Sign-up Genius (SUG):

The PHSC Band Boosters will notify parents regarding volunteer opportunities through SignUpGenius. Our secretary will send out a sign-up genius for donations and volunteers. For those new parents, a sign-up genius is used by the boosters to let you know when we need volunteers, food donations and other events for our band family. You may only sign up yourself, your spouse or your child(ren). Please note any exceptions when signing up (such as maximum sign ups etc). We want to give everyone opportunities to sign up to help.

Remind for Marching Tigers:

Remind is a free, safe, and simple messaging tool that helps teachers share important updates and reminders with students and parents. Subscribe by text, email or using the Remind app. All personal information is kept private. Teachers will never see your phone number, nor will you see theirs.

To receive messages via text, text @stowphscmb to 81010. You can opt-out of messages at any time by replying, ‘unsubscribe@stowphscmb’.

Trouble using 81010? Try texting @stowphscmb to (734) 961-4103.

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Volunteers:

The importance of volunteering. Simply put, we cannot do this without you – we are only able to pursue our shared ambitions and vision for the program with the support of the parents.

Volunteering opens the unique opportunity to interact with the students in our program, contribute to the program’s overall success, and witness the musical and personal growth of our students. If you are interested in learning more about volunteer opportunities, please attend our monthly Booster Meetings or you can send a message to any of our Executive Board members.

Thank you for all that you do.

2019 – 2020 Marching Tigers Band Camp Schedule

Sunday July 21:

• 12:30 - 2:00 Registration in Commons (booster fee due)

• 2:00 - 5:00 Full Band PAC

• 5:00 - 6:00 Dinner (plan on packing a sack dinner, drinks available in

Commons)

• 6:00 - 9:00 PM Field rehearsal

Monday July 22:

• 8:00 - 12:00 Field Rehearsal

• 12:00 - 1:00 Bring Sack Lunch (drinks available in Commons)

• 1:00 - 3:45 Music rehearsal/sectionals

• 3:45 - 6:30 Dinner Break - Relax! Go home, rest and eat dinner.

• 6:30 - 9:00 Field Rehearsal

Tuesday July 23:

• 8:00 - 12:00 Field Rehearsal

• 12:00 - 1:00 Bring Sack Lunch (drinks available in Commons)

• 1:00 - 3:45 Music rehearsal/sectionals

• 3:45 - 6:30 Dinner Break - Relax! Go home, rest and eat dinner.

• 6:30 - 9:00 Field Rehearsal

• 9:00 - 10:00 Talent Show

Wednesday July 24:

• 8:00 - 12:00 Field Rehearsal

• 12:00 - 1:00 Bring Sack Lunch (drinks available in Commons)

• 1:00 - 3:45 Music rehearsal/sectionals

• 3:45 - 6:30 Dinner Break - Relax! Go home, rest and eat dinner.

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• 6:30 - 9:00 Field Rehearsal

Thursday July 25:

• 8:00 - 12:00 Field Rehearsal

• 12:00 - 1:00 Bring Sack Lunch (drinks available in Commons)

• 1:00 - 3:45 Music rehearsal/sectionals

• 3:45 - 6:30 Dinner Break - Relax! Go home, rest and eat dinner.

• 6 :30 - 8:00 Students report to field

Parents report to PAC (performing arts center) - short concert.

Band Dance to be announced after concert

Friday July 26:

• 8:00 - 12:00 Field Rehearsal

• 12:00 -12:30 Bring Sack Lunch (drinks available in Commons)

• 12:30 Band Pictures - Band Camp ends at the conclusion of the group

photo

MARCHING TIGER UNIFORMS

The definition of a uniform is “The distinctive clothing worn by members of the same organization i.e. band.” Marching Tigers wear uniforms in the following manner:

Wear lightweight, light colored shorts, leggings or long johns. Absolutely no jeans or jean shorts under uniform – no zippers, buttons, belt loops or pockets.

Wear your show shirt, or white collarless t-shirt/long sleeve shirt under your jacket – no collars, hoodies or bulky clothes

Piercings:

• Cover new piercings with bandages – no necklaces, bracelets, earrings nose rings/studs or other jewelry. No exceptions regardless of gender.

Shoes:

• Wear white band shoes (Magic erasers work wonders)

• Clean white portions of band hats in the same manner

• Wear completely white tennis shoes with summer uniforms – no logos, sequins, or other insignia – No exceptions

• Guard and Field Commanders wear black guard shoes:

Sock Styles:

• “No show” white socks with summer uniform;

• White crew socks with white bibbers

• Black crew socks with purple bibbers

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Gloves:

• White gloves are distributed at the start of marching season. Please place 3 pairs aside to use for Competitions.

• Gloves are $2 a pair at any other time and will be charged to your child’s Charms

account.

• New guard members gloves and cymbal gloves are issued at the start of the marching season. Replacements are available for purchase for $3

Hair:

Wear hair pulled up and tucked in the band hat. All hair must be under your hat – no hair should touch collars. No exceptions regardless of gender.

CARE AND KEEPING OF A MARCHING TIGER UNIFORM

Pickerington Marching Tigers are known for their hard work and exceptional marching ability.

SUMMER UNIFORM COMPONENTS: BAND FIELD COMMANDER GUARD

Purple Band shorts White skort (girls) / Shorts (guys)

Purple Skort

White Polo with Marching Tiger embroidery

White Field Commander Polo

White Sleeveless Guard Polo

White no show socks White no show socks White no show socks

White tennis shoes/band shoes

White tennis shoes/band shoes

White tennis shoes/band shoes

The care and keeping of the summer uniform is your responsibility

FULL UNIFORM COMPONENTS:

BAND FIELD COMMANDER GUARD

Purple Bibs / Black crew socks

Black Tux pants / Black socks

Black Tap pants

White Bibs/White crew socks Black Tuxedo Jacket Issued uniform

Purple Jacket White Tuxedo Shirt Black Socks

Gloves as appropriate White gloves Black gloves

Band Hat /Plume as issued Matching Bow Ties Hair Piece

White T-shirt/Show shirt Black Shoes

White Band Shoes Matching Vests / Cummerbunds

Warm up jacket and pants Warm up jacket and pants Warm up jacket & pants

Rain coat Rain coat Rain coat

Your uniform jacket, pants, and plumes will be distributed before

each performance and stored in Central’s uniform room.

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Rain coats will be distributed when needed.

Shoes, hats, gloves, socks, and ponchos are your responsibility. These items should not be stored in the band room unless they are in a locked locker. Your duffel bag has enough space to hold these.

Shoes and hats are to be clean. A magic eraser cleans the white areas well.

Uniforms are sent out for cleaning as needed and scheduled. If your uniform is not returned to the band room after a performance and it is a cleaning night, you will be responsible for the cost, drop off, and pickup of the DRY CLEAN ONLY uniform. Hill Road Cleaners (443 Hill Road, 614-833-8662) is the only approved dry cleaner in Pickerington.

After a performance, please use your labeled hanger and neatly hang your uniform. Remember we will be watching you. Leadership should assist with this. If leadership teaches the correct care of the uniform, the uniform brigade will be happy.

CHARMS

Accessing Charms:

1. Log on to www.charmsoffice.com

2. Click the “ENTER/LOG IN” link located at the upper right corner. 3. Locate the “PARENT/STUDENT/MEMBERS/LOGIN” section of the web page.

4. Log into your child’s program accounting using the following School Code:

PHSCBAND

❖ When you enter your child’s ID NUMBER (######) as a Student Area Password, another more detailed screen appears with even more options to view your student’s uniform assignments, music assignments, financial records, forms and inventory. Once you have first entered this ID number, you may create your own unique password by clicking on the “lock” (Change Password) icon.

❖ Two areas in which you can help the Boosters maintain his/her records:

➢ Update Personal Information -- You may help make changes to your child’s student information page (such as updating phone numbers and email addresses if they change) to help the teacher communicate with you more effectively. Click the Personal Info button.

➢ You can make credit card payments for fees, trips and deposits to your student’s account. Under the section Finances, you will see a blue button marked “MAKE MISCELLANEOUS PAYMENT” on top of the student statement. You have the ability to make online credit card payments through Paypal.

Please state in the description box a brief description of the purpose of your payment i.e. On Account, Trip payment, Fundraising, etc.

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❖ Most importantly, the parent page assists both you and the teacher to communicate with each other. Stay up to date on what’s going on with your student!

Please note that the student ID number is unique to only the online Charms program. Your student’s ID number through Infinite Campus will not change and your information is protected through the school district. Questions may be directed to Carol Lawson phscbbtreasurer@gmail.com

PCHS STUDENT FORMS

The following forms are either attached or a link is provided. Please print the forms and have them ready to be turned in on the first day of Band Camp at the PHSC Cafeteria between 12:30 to 2 pm.

Student Information Form

Student Financial Hardship Form

Non-Athletic Extracurricular Responsibility Acknowledgment form –

Pre-Planned Absent Form

Pickerington Local School - Student Emergency Medical Form:

Emergency Medical Authorization Form:

Financially Disadvantaged Student Fee Application:

https://www.pickerington.k12.oh.us/wp-content/uploads/2017/07/Financially-Disadvantaged Student-Fees-App- UPDATED-1.pdf

Volunteer Application Form:

Individuals interested in volunteering in our schools or for the boosters must fill out a volunteer application yearly and submit it to a building principal. Level 2 background checks are god for 5 years, but you must still fill the form out yearly. We encourage all of our volunteers to get a level 2.

https://www.pickerington.k12.oh.us/wp-content/uploads/2016/06/Vol-Code-of-Conduct-1-1.pdf

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STUDENT / PARENT INFORMATION (in order to receive mass booster emails, we must have a current parent email address on file. If your email

has changed please highlight it so we are aware.)

PLEASE PRINT CLEARLY:

STUDENT:

Name: Grade in fall:

Address:

Instrument: Phone: (H) or (C)

Email Address:

PARENT/GUARDIAN : Relationship:_________________

Name: Phone:

Address:

Email Address:

PARENT/GUARDIAN: Relationship:_________________

Name: Phone:

Address:

Email Address:

Registered families are limited to two (2) voting members and each voting member shall have one (1) vote. For example, 2 parents in the same household may vote; or 2 parents in different households; or a parent and a step parent, etc. Voting member MUST be registered members and have a child in the High School band program.

Voting Member 1:___________________________________________________________________ Voting Member 2:____________________________________________________________________

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Student Financial Hardship Form

STUDENT NAME:

Please briefly explain your request for a financial payment plan. Please let us know how

and when you will be able to pay the band booster fee for the 2019 - 2020 school year.

It is essential that we have this information now in order to plan for this year’s activities.

Provide a payment schedule with dates below:

Parent Signature:

Treasurer Signature:

Date:

Have you applied to the PLSD for Pay to Participate Assistance? Y N

All information will be kept in strict confidence with the Pickerington Central Music Boosters

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Non-Athletic Extracurricular Responsibility Acknowledgment

STUDENT NAME: Please Print

Prior to participating in any extracurricular activity, each student must return this form, properly signed, to his/her advisor.

As a Pickerington High School student participating voluntarily in extracurricular activities, I understand that:

1. I will abide by the Pickerington School code of conduct;

2. I will conduct myself in an exemplary social manner at all times;

3. I will not use or be in possession of tobacco, alcohol or narcotics. If I do use any of these substances, am in possession of such substances or am suspended from school for use or possession of these substances, I will be subject to disciplinary action as outlined in the Extracurricular Activity Code of Conduct and

4. I, along with my parents, certify that I have read and understood the Extracurricular Activity Code of Conduct and in order to be eligible for participation I must comply with all the requirements listed.

Student Signature Date

Parent Signature Date

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Pickerington Central Marching Tigers

Pre-Planned Absence Form

Student Name:

Date: Grade: Instrument:

Student Contact Info:

Date(s) of Absence:

Reason for Absence:

• Planned absences need to be given to a director two (2) weeks prior to any missed performances or one (1) week prior to a missed rehearsal.

• Emergency absences must to be communicated to a director by the next scheduled event or the absence will be considered unexcused.

Student Signature:

Parent Signature:

For Director’s Use

Date received by Director: Excused Unexcused

Unexcused:

Resolution:

Director’s Signature: Date Resolved:

Student’s Signature:

Parent’s Signature:

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3313.712 Ohio Revised Code

Emergency Medical Authorization.

As used in this section, "parent" means parent as defined in section 3321.01 of the Revised Code.

Annually the board of education of each city, exempted village, local, and joint vocational school district shall, before the first day of October, provide to the parent of every pupil enrolled in schools under the board's jurisdiction, an emergency medical authorization form that is an identical copy of the form contained in division (B) of this section. Thereafter, the board shall, within thirty days after the entry of any pupil into a public school in this state for the first time, provide his parent, either as part of any registration form which is in use in the district, or as a separate form, an identical copy of the form contained in division (B) of this section.

When the form is returned to the school with Part I or Part II completed, the school shall keep the form on file, and shall send the form to any school of a city, exempted village, local, or joint vocational school district to which the pupil is transferred. Upon request of his parent, authorities of the school in which the pupil is enrolled may permit the parent to make changes in a previously filed form, or to file a new form.

If a parent does not wish to give such written permission, he shall indicate in the proper place on the form the procedure he wishes school authorities to follow in the event of a medical emergency involving his child.

Even if a parent gives written consent for emergency medical treatment, when a pupil becomes ill or is injured and requires emergency medical treatment while under school authority, or while engaged in an extra-curricular activity authorized by the appropriate school authorities, the authorities of his school shall make reasonable attempts to contact the parent before treatment is given. The school shall present the pupil's emergency medical authorization form or copy thereof to the hospital or practitioner rendering treatment.

Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts to comply with this section.

The emergency medical authorization form, provided for in division (A) of this section, is as follows: (See next page)

PLEASE PRINT AND ATTACH THIS FORM TO THE EMERGENCY MEDICAL

AUTHORIZATION FORM ON THE NEXT PAGE

EMERGENCY MEDICAL AUTHORIZATION

School:

Student Name: Birth Date: Grade: Homeroom:

Address: Telephone:

Purpose: To enable parents and guardians to authorize the provision of emergency treatments for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

PART I OR PART II MUST BE COMPLETED

PART I - TO GRANT CONSENT

I hereby give consent for the following medical care providers and local hospital to be called:

Doctor: Phone:

Dentist: Phone:

Medical Specialist: Phone:

Local Hospital: Emergency Room Phone:

• In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by

another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

• This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

• Pertinent health information will be shared with appropriate school staff only on a need-to-know basis.

• Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a

physician should be alerted:

Date Signature of Parent/Guardian

PART II - REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:

Date Signature of Parent/Guardian

Residential Parent or Guardian Information Home Phone Work Phone Cell Phone E-mail Address

Mother’s Name:

Father’s Name

Alternate Contact Name:

Address: Relationship to child:

HEALTH HISTORY Have or subject to: (Check if YES)

Asthma Heart Trouble

Fainting Spells Convulsions Diabetes

Swimming or Sport Restrictions Allergy or reaction to any medication Other

Describe:

PLEASE CHECK HERE IF NONE OF THE ABOVE APPLIES

Have difficulty with:

Any condition now requiring regular medication: If yes, name, and type:

Any restrictions of activity for medical reasons? Explain: _

EMERGENCY MEDICAL AUTHORIZATION

TO BE RETURNED FULLY COMPLETED BEFORE BAND CAMP

Eyes, Ear, Nose, Throat Menstrual Problems Measles Lungs Bed Wetting Mumps Digestion Sleepwalking Chicken Pox Whooping Cough German Measles Diphtheria

Grades 7-12: 1. Neither prescriptions nor non-prescription medication will be administered by school personnel or by

chaperones to students in grades 7-12.

2. Students who must have medication are to bring only the dosage for that particular day and administer the medication by themselves.

3. Ace Bandages – only for those injured at camp or on a trip. If student has a known / chronic problem, student should bring own

Name: DOB: Age:

Address:

City / Town: State: Zip:

Home Phone: Student Social Security Number:

Work/cell phone Mother: Work/cell phone Father: __

IN CASE OF EMERGENCY NOTIFY: (IF GUARDIAN CANNOT BE REACHED): Name:

Address:

Phone:

IMMUNIZATIONS – Date of Last Inoculation

*** Tetanus Toxoid: Measles

Polio German Measles (Rubella)

Mumps Diphtheria

***If you daughter/son is allergic to latex please check here:

Medical Insurance Company:

Name in which insurance is listed:

Group Number: Insurance Identification No.: