Johnston County Middle School Band Camp Application

Applicant Name:*

First

Last

Parent Name:*

First

Last

Address:*

Street AddressCityPostal / Zip Code

E-mail:*

Contact Phone:*

Area Code

Phone Number

Instrument:*

Middle School:*

T-Shirt Size:*

Grade:*

Rising 6th Grader

Rising 7th Grader

Rising 8th Grader

6th Grade ONLY:

I already own an instrument or plan to purchase before camp

I will be renting my instrument through Music and Arts

I will be renting my instrument through Edwards Musics

Medical Release

Parent/Guardian Name:*

First

Last

Childs Name:*

First

Last

Emergency Phone:*

Area Code

Phone Number

Special Medical Concerns/Conditions:*

Medical Insurance Company:*

Insurance Policy Number:*

Physician Name:*

Physician Phone:*

Area Code

Phone Number

As parent and legal guardian I authorize the staff of this event to seek, obtain and consent to treatment for my child listed on this form as deemed necessary by a licensed medical or healthcare professional. This authorization covers the entire time my child is a student at the band camp.*

Acknowledge