2019 Senior Honor Choir Medical Information

Student Mailing Address *

Parent Address (if different than above)

Doctor's Address *

Hospital Address *

Medical Insurance Company Address *

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. *

Clear
I hereby authorize the Honor Choir staff permission to obtain the necessary emergency attention or medical services for my student. *

Clear
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. *

Clear
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

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
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm