SAFFORD SCHOOLS - PERMISSION TO PARTICIPATE IN MUSIC

*********PLEASE USE BLACK OR BLUE INK TO FILL OUT THIS FORM. THANK YOU********

NAME DATE OF BIRTH GRADE _____

Home Ph. ______Father’s Name __Mother’s Name ______

Work Phone Numbers for: Father______Mother______

WHO CAN WE CONTACT IN THE CASE OF AN EMERGENCY IF YOUR PARENTS ARE NOT AVAILABLE: ______at ______

PARENT CONSENT TO PARTICIPATE

I / We give our permission for the above named student to participate in organized school music program (s), realizing that such activity involves travel during and outside of the regular school day, which is an inherent requirement in any performing ensemble.

EXTRA CURRICULAR ACTIVITIES INSURANCE

____I certify we have MEDICAL AND HOSPITAL INSURANCE to cover the above named student.

NAME OF COMPANY: ______POLICY #

COMPANY ADDRESS______GROUP#______

____I DO NOT HAVE MEDICAL/HOSPITAL INSURANCE TO COVER THE ABOVE NAMED STUDENT. I REALIZE THAT I WILL NEED TO PURCHASE SCHOOL INSURANCE TO COVER MY SON/DAUGHTER.

For Office Use Only School Receipt Number______Date paid______

CONSENT FOR EMERGENCY MEDICAL CARE

FAMILY DOCTOR: ______

Be it know that I, the undersigned parent or guardian of the student named above hereby give and grant unto any medical doctor or hospital my consent and authorization to render such aid, treatment or care to said student as, in the judgment of said doctor or hospital may be required, on an emergency basis, in the event said student should be ill or stricken ill while participating in or traveling to or from any official music event or any musical even planned by Safford Unified School District, including those endorsed by the Arizona Interscholastic Association, Inc. of which SAFFORD Schools is a member. It is hereby understood that the consent and authorization hereby given and granted is continuing, and are intended by me to extend throughout the current school year.

I APPROVE OF MY SON/DAUGHTER PARTICIPATING IN MUSIC EVENTS UNDER THE DIRECTION OF A TEACHER FROM SAFFORD SCHOOL DISTRICT (or other designated representative), INCLUDING THOSE SANCTIONED BY THE ARIZONA INTERSCHOLASTIC ACTIVITIES AND THE MUISC PROGRAMS OF SAFFORD SCHOOLS,THE A.I.A AND EAJHA.

I/We, parent(s) and/or guardian(s) acknowledge that I/we grant permission to participate, consent for medical care, verification of insurance which govern eligibility to participate in music programs at Safford Schools both within and outside of the regular school day.

DATED the ______day of ______200_____, at Safford, Arizona.

Parent or Guardian: ______Student: ______