2012-2013 Wind Ensemble Permission Slip

2012-2013 WIND ENSEMBLE PERMISSION SLIP

AND MEDICAL FORM

I ______, parent or guardian of ______

give my child permission to participate in the wind ensemble at Montgomery Ridge for the 2012-2013 school year.

PLEASE INITIAL EACH STATEMENT

_____ My child will attend EVERY wind ensemble rehearsal.

_____ I understand that the ONLY excused absences are due to illness (absent from school that day) AND family bereavement.

_____ I understand that ONE unexcused absence could result in dismissal from the wind ensemble.

_____ I understand that TWO or more excused absences could result in dismissal from the wind ensemble.

_____ I realize correct conduct and behavior is required for wind ensemble participation.

_____ I realize there are no refunds.

_____ I realize this experience is part of the MRIS Spring Intersession and that some of this event occurs during the first part of the Spring Break Intersession time.

_____ I give permission for my child to attend the concert festival at Farragut High School on March 14th, 2013.

_____ I give permission for my child to travel to Dollywood on Saturday, May 4th.

PLEASE ONLY INITIAL WHERE APPLICABLE

_____ I and perhaps other family members wish to attend the concert festival at Farragut on March 14th to support the wind ensemble, be in the audience cheering section and chaperone while at the event (chaperones always drive separately from the student bus).

_____ I wish to be a chaperone for the DollyWood trip on May 4th, and I will need an additional _____ (number) of tickets to Dollywood at a cost of $50.00 ea. (includes admission and meals). Chaperones always drive separately from our student bus.

Please list names of adults and siblings wishing to attend: ______

______

_____ I wish to pay $150.00 in full (plus $50.00 for each additional person attending DollyWood) for the wind ensemble experience.

_____ I wish to pay a $50.00 deposit and then $50.00 a month or more for November, and January and other fees (chaperones and siblings) in February.

_____ My child takes or will take private lessons.

MEDICAL INFORMATION

PLEASE INITIAL EACH STATEMENT

_____ I give a permission for my child to receive medical attention in the unlikely event of an emergency.

_____ I do not hold Maryville City Schools liable or responsible for accidental injury

_____ My child will have medical insurance information on their person for our (2) field trips.

_____ All of my child’s medical information and medicines (prescription and over-the-counter) are updated with MRIS and will be current at time of field trips so that all pertinent and necessary medicines, inhalers, etc. and medical concerns are known by the field trip personnel.

Medical Insurance Company ______

Medical Insurance Policy Number ______

Please list prescription and over-the-counter medicines needed for your child. Please indicate with a “*” (star) which ones that will be needed on our field trips.

Please list any other medical concerns or issues:

All Phone Numbers:

X ______Parent or Guardian Signature

Please place public notary seal here:

Public Notary Signature and Authorization Code:

X ______