Handbook Signature Pages 2024-2025

2024-2025 Financial Agreement

Cordova High School
The Cordova High School Band is a co-curricular activity. There is a minimum amount of money needed for this program to run and succeed. The financial commitment required from each member is called the Band Club Fee. Many fundraisers are organized by the band booster organization to raise monies that can be applied to a student's individual Band Club Fee Account.

Accessories such as reeds, socks, mouthpieces, Stockings (guard), etc. are not included in the Band Club Fee and must be paid for separately.

1. Band Club Fee payments must be up to date by the time of the performance for the student to receive proper uniform. Without the proper uniform, the student will be unable to perform!!! The student WILL NOT be able to perform or participate in performances if the fees are not up to date.

2.Students WILL receive Debt Slips for unpaid Band Club Fee beginning the start of the second Semester.

Failure to pay this OBLIGATION may result in the student's ability to attend school events, registration, pick up report cards, or participate in graduation.

3. Band Club Fee payments are NON-REFUNDABLE and must be paid in full for the academic school year, regardless of withdrawal, suspension, or removal from the band.

I, the undersigned parent/guardian, of the undersigned student have read and agree with all of the above statements regarding the Band Club Fee and obligation. I understand that being a member of the band requires participation in fundraisers for my child's Band Club Fee and/or I agree to pay the balance of funds that are not raised. I agree to adhere to the payment schedule and understand that failure to do so will result in consequences listed in "Notices", above.
(STUDENT NAME PRINTED)*
(STUDENT SIGNATURE)*

Clear
(PARENT'S NAME PRINTED)*
(PARENT SIGNATURE)*

Clear
(DATE)*

MonthDayYear
Date
In order for the band to function, these payments need to be made promptly. If you have any questions or problems, please do not hesitate to contact the Band Director.

Payment Schedule Selection

Please select the correct payment schedule for your student (instrumentalist, majorette, or color guard). (Please note that a 5% convenience fee will be added if paying online.)
Payment Option*

Instrumentalist $500 (7/19, 8/16, 9/13, 10/11, 11/15)Majorette Payment ScheduleColor Guard Payment Schedule
(PARENT'S NAME PRINTED)*
(PARENT SIGNATURE/GUARDIAN)*

Clear
(DATE)*

MonthDayYear
Date

2024-2025 Letter of Mutual Consent
I, the undersigned student, accept membership in the Cordova High School Band and understand that I am responsible for the policies as set forth and required by the Cordova High School Band Handbook. I fully agree to carry out all of my responsibilities to the best of my ability.
(STUDENT NAME PRINTED)*
(STUDENT SIGNATURE)*

Clear
(DATE)*

MonthDayYear
Date
I, the undersigned parent or guardian, have read and understand the policies as set forth by the Cordova High School Band Handbook. I also grant full permission for my child to be an active member of the Cordova High School Band program. In addition, my child has full permission to attend and participate in all band functions. Furthermore, I understand that I must meet all financial obligations.
(PARENT'S NAME PRINTED)*
PARENT/GUARDIAN SIGNATURE (PARTICIPANT IF 18 OR OLDER)*

Clear
(DATE)*

MonthDayYear
Date

Student Information

Please fill out the information below.
STUDENT(S) NAME(S)*
PARENT(S) NAME(S)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
STUDENT'S CELL PHONE*
MOTHER'S CELL PHONE*
FATHER'S CELL PHONE*
HOME PHONE
MOTHER'S WORK PHONE
FATHER'S WORK PHONE
MOTHER'S EMAIL*
example@example.com
FATHER'S EMAIL
example@example.com
STUDENT'S EMAIL*
example@example.com

ASSUMPTION OF RISK AND RELEASE FOR ACTIVITIES ON PROPERTY OR IN CONJUCTION WITH THE MEMPHIS SHELBY COUNTY BOARD OF EDUCATION
In consideration of being permitted to participate in the recreation, athletic, cheering, dance program, clinic, or band camp conducted by Cordova High School Band.
I, the undersigned parent and student, do hereby agree to assume all the risks and resposibilities thereto.

Further, I hereby represent to the Memphis Shelby County Schools that I am capable of participation in this activity and understand that participants must consult a physician prior to any participation.

And, I hereby recognize the risks of illness and injury inherent in any activity based program and I am participating upon the expressed agreement and understand that I do for myself, my heirs, and personal representatives agree to defend, hold harmless, indemnify, release, and forever discharge Memphis Shelby County Schools, its representative officers, Roderick N. White, Jr., agents, representatives and employees from and against any and all rights, claims, demands, and actions or causes of actions - including attorney's fees and court costs - on account of damage to personal property, personal injury or death which may result from any participation in the Cordova High School Band and/or associated activities.

By my signature below, I hereby confirm my understanding of this release statement holding Schools harmless and acknowledge that they do not carry health and accident insurance to cover participants of this program and that participants are encouraged to obtain full insurance coverage prior to participation in the Cordova High School Bands and/or associated activities.

I HAVE READ AND UNDERSTAND THE CONTENTS OF THE CORDOVA HIGH SCHOOL BAND HANDBOOK. THE INFORMATION FURNISHED ON THIS FORM IS ACCURATE. I, THE UNDERSIGNED BEING THE PARENT, LEGAL NEXT OF KIN, OR LEGAL GUARDIAN, HEREBY AUTHORIZE ANY NECESSARY MEDICAL TREATMENT FOR THIS PERSON WHILE HE/SHE IS PARTICIPATING IN THE CORDOVA HIGH SCHOOL BAND AND ASSOCIATED ACTIVITES. I ALSO GUARANTEE PAYMENT OF ALL CHARGES INCURRED DURING THIS. (PHYSICIAN, HOSPITAL, X-RAY, LAB, MEDICATION AMBULANCE, ETC) I UNDERSTAND THAT IN CASE MY CHILD SHOULD NEED TESTING OR SERIOUS MEDICAL ATTENTION THAT I, THE PARENT WILL BE CALLED IMMEDIATELY FOR GUIDANCE ON THE SITUATION. I ALSO UNDERSTAND THAT THE RULES HAVE BEEN SET FORTH BY THE BOARD OF EDUCATION, CORDOVA HIGH SCHOOL, AND RODERICK N. WHITE, JR., THE DIRECTOR OF BANDS FOR THE BENEFIT OF ALL PARTICIPANTS. I UNDERSTAND THAT I RELEASE MEMPHIS-SHELBY COUNTY SCHOOLS, CORDOVA HIGH SCHOOL, RODERICK N. WHITE, JR., ALL BAND STAFF MEMBERS, AND CHAPERONES FROM ANY KIND AND ALL LEGAL MATTERS CONCERNING MEDICAL OR DISCIPLINE.
PARTICIPANT SIGNATURE*

Clear
DATE*

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE (PARTICIPANT IF 18 OR OLDER)*

Clear
DATE*

MonthDayYear
Date

EMERGENCY MEDICAL INFORMATION
Name*
Cell Phone*
Date of Birth*

MonthDayYear
Date
Home Phone
Mother's (or guardian's) Name*
Work Phone
Cell Phone*
Father's (or guardian's) Name*
Work Phone
Cell Phone*
Please list an emergency contact if you are unreachable:
Emergency Contact*
Phone*
Family Physician*
Phone*
Is this child allergic to any medicines or insect bites?*
Other known physical or health problems, or is this child on medication?*
In case of accident or serious illness, I hereby authorize the school or its designated representatives to make whatever arrangements are necessary with whatever doctor/nurse is available to give all necessary treatments to my child.
Parent Signature*

Clear
Date*

MonthDayYear
Date
In case of minor medical issues such as headaches, upset stomachs, sprains etc., I give my child permission to take over the counter medicines administered by the nurse.
Parent Signature*

Clear
Date*

MonthDayYear
Date

PERMISSION TO USE PHOTOGRAPHS/VIDEO
The Cordova High School Band website or any other social media may contain photographs and/or video of students. Because there will be pictures included on this site, it is necessary for me to obtain a signed waiver from a parent/guardian before a picture or video of any student can be put on the website. If for some reason you do not want your child's picture on the website, please sign the appropriate area.

I give permission to Mr. Roderick N. White, Jr. and/or the web master to place any picture that includes my son/daughter, on the Cordova High School Band Website. Furthermore, I release Memphis Shelby County Schools, Cordova High School, Roderick N. White, Jr. and all Band Staff Members from any kind and all legal matters concerning the use of my child's picture or image.
PLEASE SELECT FROM THE FOLLOWING*

I DO GIVE PERMISSION to Mr. Roderick N. White, Jr. and/or the web master to place any picture that includes my son/daughter on the Cordova High School Band Website.I DO NOT GIVE PERMISSION to Mr. Roderick N. White, Jr. and/or the web master to place any picture that includes my son/daughter on the Cordova High School Band Website.
PARENT/GUARDIAN SIGNATURE (PARTICIPANT IF 18 OR OLDER)*

Clear
DATE*

MonthDayYear
Date

Playing Test Rubric Delivery Selection
Please select your preferred method of receiving your playing test rubrics*

Email (Non-MSCS Email)Printed Copy
Please enter preferred email if that choice was selected.
example@example.com

FIELD TRIP FORM 2024-2025
I give permission for my son/daugther, to participate in all school-sponsored trips away from the school premises throughout the current school year. Students will be accompanied by Roderick N. White, Jr. and will be adequate adult supervision. I understand that I will be given at least forty-eight hours' notice of all trips away from the school premises. I further understand that I may revoke permission for a specific field trip by written notice to Roderick N. White, Jr. more than one week prior to the trip.

Although the school desires to provide a safe and enjoyable time for all students, accidents can still happen. I/we understand that there are risks/dangers involved with participation in off-campus trips and their associated activities. In consideration of my child being allowed to participate in the trip, I/we agree to assume responsibility for those associated with the travel and activities. I/we agree to hold harmless Memphis Shelby County Schools, Cordova High School, Roderick N. White, Jr. and representatives, including volunteer(s) and other drivers, from any and all claims arising from my child's participation. This release agreement does not apply to claims of intentional misconduct or gross negligence by the school, its employees, or volunteer(s).

In case of accident, illness, or other emergency, I/we request that Roderick N. White, Jr. contact me. If Roderick N. White, Jr. cannot reach a parent/guardian after conscientious effort, I/we give permission for Roderick N. White, Jr. to call paramedics or any licensed physician or dentist. If a life-threatening emergency exists, I/we give permission for Roderick N. White, Jr. to call paramedics immediately and then contact me/us as soon as possible thereafter.

I/we authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care, which, in the best judgment of a licensed physician or dentist, is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I/we also agree to be financially responsible for emergency medical transportation. In cases where medical care is needed but the situation is not an emergency, Roderick N. White, Jr. will make every effort to contact parents before treatment is given.
(Student Name)*
(Student Signature)*

Clear
Date*

MonthDayYear
Date
(Parent Name)*
(Parent Signature)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

2024-2025 Financial Agreement

Payment Schedule Selection

2024-2025 Letter of Mutual Consent

Student Information

ASSUMPTION OF RISK AND RELEASE FOR ACTIVITIES ON PROPERTY OR IN CONJUCTION WITH THE MEMPHIS SHELBY COUNTY BOARD OF EDUCATION

EMERGENCY MEDICAL INFORMATION

PERMISSION TO USE PHOTOGRAPHS/VIDEO

Playing Test Rubric Delivery Selection

FIELD TRIP FORM 2024-2025