Chelan Music Department

Participation Contract 2006-2007

I have read and understand all components of the Chelan Music Department Student Handbook including grading criteria, expectations, required performance dates, and overall information for membership in the CMD. I agree to comply with the aforementioned and offer my signature and my parent’s signature as confirmation.

Student Name: ______________________________________________________ Grade:_____

Instrument/Voice Part:___________________________________________________________

Band Members Please Complete The Following:

Instrument Brand Name:____________________________ Serial Number:_________________

Please Check One: ___Own ___*Rent ___School

*Name of Rental Company:_______________________________________________________

If renting, do you have Maintenance Replacement Guarantee? ___YES ___NO

Mother’s Name:________________________________________________________________

Address:______________________________________________________________________

Home Phone:______________ Work Phone:______________ Email:______________________

Father’s Name:_________________________________________________________________

Address (If different than mother):__________________________________________________

Home Phone:______________ Work Phone:______________ Email:______________________

If a parent needs to be contacted, who should Mr. Burdick call?__________________________

When and where is the best time to reach you?________________________________________

___________________________ _______________________ ____________

Parent Signature Student Signature Date

Chelan Music Department

Activity Permission Slip & Medical Release

I am aware that as a participant in a school sponsored field trip, or any other trip, there are both known and unknown dangers that may occur, including but not limited to the hazards of travel, accidents or illness, the forces of nature and travel by air, bus, automobile, or other conveyance.

In consideration of participation in any field trip this year, I have and do hereby assume all known and unknown risks of danger which may arise of or in connection with participation in said field trips, and will hold all employees, staff, and/or agents of the Lake Chelan School District No. 129 harmless from any and all liability as a result from such participation. The terms thereof shall serve as a release and assumption of risk for myself, my heirs, executor and administrators, and for all members of my family.

Your signature below indicates you have read the disclaimer and agree to said conditions and content. Your signature gives permission for your student to participate in field trips and activities related to their participation in the Chelan Music Program. Your signature will also serve as an emergency medical release compliant the statement below.

In the event of illness or injury occurring while the individual named below is participating in said activities, I hereby consent in advance to any medical treatment or procedure that is considered necessary by any supervising party. I understand in the event of a serious illness or accident, reasonable efforts to reach parent/guardian or closest relative/friend will be attempted.

Student:_______________________________________________________________________

Home Phone:________________________________ Work Phone:_______________________

Relative/Friend Name and Phone:__________________________________________________

Insurance Provider:___________________________________________Policy #:____________

Please list any medical conditions, medications, allergies and/or other information pertinent to your students health, that would be beneficial for staff and medical personnel in an emergency situation:______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Parent Signature:_________________________________________ Date:__________________