PCHS BAND & COLOR GUARD PERMISSION SLIP & HEALTH INFORMATION
DATE: ______________ STUDENT''S FULL NAME ____________________________________________
I give my son/daughter permission to participate and travel with the Port Chester High School Band for all
scheduled  events and activities. I understand that my son/daughter must follow the rules detailed in both
the High School student handbook and the Band handbook regarding all of these activities.

I also give permission to the Director, his assistants, or a chaperone in charge to authorize emergency medical treatment for my son/daughter, if needed. I understand that I will be notified as soon as possible of such an
occurrence.

PARENT SIGNATURE: __________________________________________


PLEASE LIST ADULT, OTHER THAN A PARENT WHO CAN BE CONTACTED IN THE EVENT OF
AN EMERGENCY:

NAME: _______________________________ PHONE#: _________________________

                                                                              CELL#: _________________________
                                      CONFIDENTIAL
Home phone #: ___________________________ Work phone #:_______________________

Parents Cell # __________________________

Student's date of birth: ____________________

Student''s Physician: _______________________ Phone #: ___________________________
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY
Pneumonia: _______ Asthma ______ Diabetes ______ Epilepsy _______

Heart problem _______ Hearing loss ________ Vision loss ________

Rheumatic fever ______ Speech problem ________ Operations _________

Allergies __________________________ Serious Injuries__________________________

Fractures __________________________ Others ________________________________

Parent's Health Insurance Carrier: _________________________

Policy #: ______________________ Insurance Co. Phone #: _________________________
                                                                                                                                                                   
Address: _________________________ City:__________________ ST:_____ Zip:_______

Check here if no health insurance: ___________