2026 Grassfield Orchestra Atlanta Trip Registration Form

Student Name

First NameLast Name

Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

Birthday

Date

Student Cell Number

Format: (000) 000-0000.

Student Email

example@example.com

Which orchestra group are you in (check all that apply)?

Student t-shirt size

Parent Name

First NameLast Name

Is Parents Address the same as student's?

Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent Email

example@example.com

Emergency Contact (When parent cannot be reached)

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Email

example@example.com

Is the above student in good health?

Does the above student have ANY special medical conditions (Ex; Allergies, Diabetes, Heart Ailment, ADD/ADHD or other) that we should be aware of?

If you answered yes, please explain below.

Does the student have Health Insurance?

Company Name

Policy/Group Number

Policy Holders Name

In the event of sickness or accident, the sponsors and/or chaperones are granted the permission to seek any and all medical attention of the above named child. Also, I grant the permission to give any and/or all needed medical care and treatment to the child to any medical facility and/or physician that are licensed to provide this care and approved by the sponsor and/or chaperone. This permission is granted in the absence of me/us as the parent or guardian of the minor child.

This trip is not insured but should you wish to purchase TRAVEL INSURANCE for your child you can do so by applying online through a company like: www.allianztravelinsurance.com

By signing below the student agrees to follow the guidelines set by school officials and the guidelines of Custom Music Tours as listed in the Terms and Conditions. By signing below the parent/guardian agrees to the medical disclosure and the terms of the financial payments and disclosures given in the contract agreement.

Parent Signature

Student Signature

Date

2026 Spring Trip Registration

Parent/Guardian Information

Medical Release