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2022-23 Instrumental Music Emergency Contact and Communication Form
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* Indicates required question
Student LPS ID #
*
Your answer
Student LAST name
*
Your answer
Student FIRST name
*
Your answer
Student Email Address
*
Your answer
Student Cell # (XXX)-XXX-XXXX
Your answer
Student T-Shirt Size (adult sizes only)
*
XS
S
M
L
XL
XXL
XXXL
Primary Parent/Guardian LAST name
*
Your answer
Primary Parent/Guardian FIRST name
*
Your answer
Primary Parent/Guardian EMAIL Address
*
Your answer
Primary Parent/Guardian Cell # (XXX) XXX-XXXX
Your answer
Secondary Parent/Guardian (optional) LAST name
Your answer
Secondary Parent/Guardian FIRST name
Your answer
Secondary Parent/Guardian EMAIL Address
Your answer
Secondary Parent/Guardian Cell # (XXX) XXX-XXXX
Your answer
Hospital/Clinic Preference
Your answer
Physician Name
Your answer
Physician's Phone #
Your answer
Insurance Company
Your answer
Insurance policy #
Your answer
Student Allergies/Special Health Considerations
*
Your answer
Parent/Guardian Special Skills: Do you weld? work construction? Sew? Cook for 400 people? Love to Chaperone? Please tell me if you have a skill to offer the program. No amount of help (except none:)) is too little.
Your answer
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