LCM BAND STUDENT REGISTRATION & HEALTH HISTORY

Student's Full Name

First NameLast Name

Student's Cell Phone Number

Student's Date of Birth

Student's Gender:

Student's Grade Level:

Student's Instrument:

Student's T-Shirt Size:

Student's Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian #1

First NameLast Name

Parent/Guardian #1 Cell Phone Number

Parent/Guardian #1 Home Phone Number

Parent/Guardian #1 Email Address

Parent/Guardian #2

First NameLast Name

Parent/Guardian #2 Cell Phone Number:

Parent/Guardian #2 Home Phone Number:

Parent/Guardian #2 Email Address:

Emergency Contact in the event Parent/Guardian is unable to be reached

Emergency Contact's Phone Number

Permission to release Parent/Guardian email addresses to the LCM Band Boosters:

YesNo

Is your student currently under medical care?

YesNo

If YES, please explain:

Has your student had an operation in the last year?

Date of last Tetanus injection (if known):

Serious Medical Problems:

Additional Health Information or Concerns:

Does your child require an inhaler?

YesNo

Heart Conditions: (i.e. Rheumatic Fever, etc.)

YesNo

If YES, please explain:

Mark all applicable conditions:

Drug Allergies (i.e. penicillin, insulin, etc.):

YesNo

If YES, please explain:

Allergies Requiring Medical Treatment (i.e. latex, peanut, etc.)

YesNo

If YES, please explain

Dietary Restrictions (Food Allergies, Lactose, Vegetarian, Vegan etc.):

YesNo

If YES, please list your student's dietary restrictions and a safe meal choice from the following restaurants [Chick-Fil-A, Chicken Express, Dominos, Jason's Deli, Sonic]:

The following non-prescription medications and their generic alternatives will be available during our trips. Please check each medication you approve to be dispensed to your child as deemed necessary:

List of present regular medications:

Family Physician:

Physician Phone Number:

Health Insurance Company & Policy Number:

My signature constitutes my permission for the above named student to be treated for a medical and/or surgical emergency by a private physician or at a hospital. My signature constitutes my permission for the LCM Band staff, medic and chaperones to dispense the approved non-prescription medications to the above named student.

Parent/Guardian Name (Printed)

Parent/Guardian Signature

Clear

ACKNOWLEDGMENT OF RESPONSIBILITY AND PERMISSION FOR STUDENT PARTICIPATION IN SCHOOL SPONSORED TRIPS

I (Parent/Guardian) , agree to allow my child, (Student's Name) , to travel with a group or individual associated with LCMCISD on the trip(s) indicated below. We, the parent(s)/guardians of the student listed in this form, have discussed the trip(s) with our child and have given our permission for him/her to attend and participate. Band sponsored trips will travel by school bus, school suburban and/or charter bus and will return to school following the event.

This release applies to:
-- All 2023-2024 school year trip(s) to be taken by the Little Cypress-Mauriceville High School Band, including but not limited to: football games, marching competitions, community events, day trips and overnight trips.

We are assured that he/she will conduct himself/herself in a manner consistent with school district policies and the sponsor’s expectations. It is understood that these students will be chaperoned both enroute and while participating in the activity. It is also understood that normal precautions will be taken in the interest of their safety and well-being. We agree that the district, district employees, and/or non-employee chaperones will not be held responsible for any accident or misfortune that might occur in connection with this activity or trip.

You may be assured that our child is permitted to participate in this activity with our full consent. In the event the student becomes ill or suffers an accident while on the trip and it is deemed by the school personnel who are in charge that hospitalization or medical attention is necessary, we hereby request and authorize such action.

I understand that while student safety is a high priority for the District, under state law the school is not responsible for medical costs associated with a student injury. I expressly waive all claims for medical expenses, loss of services, or other claims, and I agree to indemnify and hold harmless the District, its Trustees, employees, and agents from all claims made against it or them on behalf of my child.

I agree to indemnify and hold harmless the District, its Trustees, employees, and agents from all claims made by third parties against it or them which result from my child's actions on the trip. I understand that the District, its Trustees, employees, and agents are not waiving any sovereign or governmental immunity which it or they have under Texas law.

OFF-CAMPUS ACTIVITIES ACKNOWLEDGEMENT

Rules and regulations are established for the safety and well-being of all. When students participate in off-campus activities, the expectations and consequences that are set forth by the Little Cypress-Mauriceville High School Student Handbook, The Student Code of Conduct, specific participating organization handbook and/or constitution, as well as other guidelines established by the sponsors, are in effect.

It is important for students and their parents to be aware that, according to the Texas Education Code (school law) and the District Student Code of Conduct (board policy), any inappropriate behavior while at a school sanctioned event – at any location – is subject to the same consequences as though the behavior occurred on the school campus. Furthermore, if school officials have reasonable suspicion that a student is in possession of articles or materials that are forbidden by the District, the sponsor will conduct a search of the student and his or her property.

Students’ participation in off-campus activities should be a productive and positive experience. It is out hope that this acknowledgement will explain expectations for off-campus activities. If you should desire further clarification, please call the assistant principal at 409-886-5821.

My signature constitutes that I have read and understand the Acknowledgment of Responsibility and Permission for Student Participation in School Sponsored Trips and sign it voluntarily and with full knowledge of its significance. My signature constitutes that I have read and agree to adhere to the expectations and consequences stated in the Off-Campus Activities Acknowledgement.

Parent/Guardian Name (Printed)

Parent/Guardian Signature

Clear

Student Name (Printed)

Student Signature

Clear

LCM BAND STUDENT REGISTRATION & HEALTH HISTORY

LCM BAND TRAVEL PERMISSIONS & ACKNOWLEDGEMENTS