February 4, 2019

Student Registration

Registration information must be provided for each student joining the band program EVERY YEAR.  This information must be provided before the start of band camp.  Fields marked with an asterisk (*) are required.  If you have any questions, please contact the BPA.

Parent Information

Parent/Guardian Name 1*
E-mail confirmation(1):*
Receive Email Notifications:*
Cell Phone(1):*
Home Phone(1):
Work Phone(1):

Alternate Contact (Optional)

Alternate Contact Name:
Alt Contact Address:
Alt Contact E-mail:
E-mail confirmation:
Alt Receive Email:
Parent/Guardian Name 2
Address(2) - if different:
E-mail confirmation(2):
Receive Email Notification(2):
Cell Phone(2):
Home Phone(2):
Work Phone(2):

Alt Cell Phone:
Alt Home Phone:
Alt Work Phone:
Additional Info:

Student Information

Student Name:*
Student lives with:*
Are there any current custody issues?*
If yes, please describe:
Student Email:*
E-mail confirmation:*
School Email (@jcsnc):
Student Cell:*
Student T-Shirt Size*
Student Grade:*
Student Birthdate:*
Participating Ensembles (check all that apply): *
Primary Instrument (including Guard):*
Check if you will have multiple siblings in the program this season:
Acknowledgement and Release   <== Click here to print

I understand and acknowledge that the Cleveland High School Band Parent’s Association, Inc. (“BPA”) is a non-profit 501c(3) that solely supports the Cleveland High School Band programs. I understand that participation in the activities supported by the BPA may expose my child to risks of injury and damage to property and I assume any such risk that may arise there from. I accept full responsibility for all medical expenses for any injuries that may occur to my child or damage to my child’s property that may occur by reason of his/her participation.

By checking the acceptance box I hereby release the Cleveland High School Band Parent’s Association, Inc., its Board members, directors, officers, agents, assigns, and volunteers (“released parties”) from and against any and all claims, demands, actions, complaints, suits, or other forms of liability of whatever kind or nature, including reasonable attorney and expert fees, and including any and all negligence claims or causes of action, which may arise and which result from illness, personal injuries, property damage, death, or any other damages or injuries, not included herein, occurring during, arising out of, or as a result of my child’s participation in the activities supported by the Cleveland High School Band Parent’s Association, Inc. Accordingly, any liabilities arising from my child’s participation are my sole responsibility. *
I confirm that I have carefully read this ACKNOWLEDGEMENT and RELEASE and agree to its terms knowingly and voluntarily. I also confirm that I am the parent or legal guardian of the child or I am a student 18 years or older. This consent and release has been read and is understood by me*

Medical Information

Doctors Name:*
Doctors Phone:*
Allergies (medication, food, etc)*
Special Medical Needs:*
Current medications:*
Date of last tetanus shot:*

Medical Insurance

Subscribers Name:*
Policy Number:*

Emergency Contacts

We will always attempt to contact the parent/guardian first.  Please provide two alternate emergency contacts (not parents) we can contact for your student(s).

Emergency Contact (primary):*
Phone1 (cell /work/home):*
Alt Phone1 (cell/work/home):*
Emergency Contact (secondary):*
Phone2 (cell /work/home):*
Alt Phone2 (cell/work/home):*
Once the registration information is received and validated, you will have access to the members website and receive email communication from the BPA and the Band.