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Nitschmann Instrumental Music Association 2019-2020 Registration Information
This form provides Mr. Zettlemoyer with your demographic information (contact information) and pertinent medical information for your child in the event of an emergency.
Please complete a separate form for each child participating.
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* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Gender
*
Female
Male
Grade
*
Your answer
Parent 1 (Legal Guardian's) Name
*
Your answer
Parent 1 Relationship to student
*
Your answer
Parent 1 Street Address
*
Your answer
Parent 1 City
*
Your answer
Parent 1 Zip Code
*
Your answer
Parent 1 Home Phone Number
Your answer
Parent 1 Cell Phone Number
Your answer
Parent 1 E-mail Address
Your answer
Parent 2 (Legal Guardian's) Name
Your answer
Parent 2 Relationship to student
Your answer
Parent 2 Street Address
Your answer
Parent 2 City
Your answer
Parent 2 Zip Code
Your answer
Parent 2 Home Phone Number
Your answer
Parent 2 Cell Phone Number
Your answer
Parent 2 E-mail address
Your answer
Student Medical Information
Please list all allergies you child has including food, medication, animals, etc. (If your child does not have any allergies write "NONE".)
*
Your answer
Will your child be carrying an EPI-PEN with him or her during summer music camp, parades, and other music ensemble functions?
*
Yes
No
Will your child be carrying an INHALER with him or her during summer music camp, parades, and other music ensemble functions?
*
Yes
No
List all prescription medications your child is taking. If none, type "NONE."
*
Your answer
List all non-prescription medications your child is taking. If none, type "NONE."
*
Your answer
Does your child have a physical condition that I should know about?
*
Yes
No
If "YES" please provide details.
Your answer
Does your child have a medical condition that I should know about?
*
Yes
No
If "YES" please provide details.
Your answer
Does your child have a psychiatric condition that I should know about?
*
Yes
No
If "YES" please provide details.
Your answer
List the name of an emergency contact that can be reached during summer music camp hours (7:30am - 12:30pm)
In case of emergency, I must be able to reach someone at the number you provide.
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
Emergency Contact relationship to student
*
Your answer
PLEASE NOTE: Parent volunteers and summer music camp staff are not authorized to administer medicine. If a problem arises the parent, guardian, or emergency contact will be notified immediately.
Do you authorize parent volunteers to administer NEOSPORIN to your child during summer music camp, instrumental rehearsals or performances?
*
Yes
No
Do you authorize parent volunteers to administer BAND AIDS to your child during summer music camp, instrumental rehearsals or performances?
*
Yes
No
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