Senior Honor Choir Medical Information
Student Name
*
First Name
Last Name
School
*
High School Attending
Voice Part
*
Soprano
Alto
Tenor
Bass
Student Mailing Address
*
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Student Phone Number
*
-
area code
phone number
Student Date of Birth
*
-
Month
-
Day
Year
Parent or Guardian Name
*
First Name
Last Name
Phone Number Parent can be reached AT ALL TIMES
*
-
area code
phone number
Parent Email
*
email@email.com
Parent Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Last Tetanus Shot
*
-
Month
-
Day
Year
Doctor's Phone Number
*
-
area code
phone number
Doctor's Address
*
Street Address 1
Street Address 2
City
State
Postal/Zip Code
Your Hospital
*
Name of hospital
Hospital Phone Number
*
-
area code
phone number
Hospital Address
*
Street address 1
Street address 2
City
State
Postal/zip code
Medical Insurance Company
*
Medical Insurance Company
We do not have Medical Insurance
Yes
Medical Insurance Phone Number
*
-
Area Code
Phone Number
Medical Insurance Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Group/Policy Number
*
Group/Policy Number
MUST UPLOAD COPY OF INSURANCE CARD *FRONT*
*
Browse Files
If you do not have Medical Insurance, please upload a blank image.
Cancel
of
MUST UPLOAD COPY OF INSURANCE CARD *BACK*
*
Browse Files
If you do not have Medical Insurance, please upload a blank image.
Cancel
of
Have you had any recent surgeries?
*
Yes
No
If so, what?
List any Allergies
List any medication that you are using.
Give any other information which would be helpful in case of an emergency.
I hereby authorize the Honor Choir staff to administer over-the-counter medications (i.e. Tylenol, Advil, Motrin, etc.) for my student.
*
I hereby authorize the Honor Choir staff permission to obtain the necessary emergency attention or medical services for my student.
*
We have read and understand the Rules and Regulations for Honor Choir camp. I give permission for any picture and/or recording of my child to be used for promotional purposes both on and off the internet.
*
T-Shirt Size *Size not guaranteed after June 1st
*
S
M
L
XL
XXL
Please type the student name as you would like it to appear on the program.
*
Student Name
You MUST select one of the payment options below.
Registration Fee Paid Online Via Paypal
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Honor Choir Registration Fee + Online Convenience Fee
$
384.00
Total
$
0.00
Registration Fee Mailed to Rogene Brown
Pay by Check or Money Order (NO CASH) $375.00
School will send Check for Registration $375.00
Submit
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