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#: _________________________

CONFIDENTIAL Home phone #: ___________________________ Work phone #:__ ______________________ 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: ___________