Student First Name :
Student Last Name :
Parent First Name :
Parent Last Name :
Email :
Phone :
Address Line 1 :
Address Line 2 :
City :
State :
Country :
Zipcode :
School Attending in Fall 2019 :
Grade in Fall 2019 :
Instrument :
For how many years? :
I Also Play :
For how many years? :
Jazz Instrument (see letter for requirements) :
For how many years? :
How are you getting your instrument? :
If renting, from where? :


Medical Information



Emergency Contact Name :
Emergency Contact Phone :
Family Physician Name :
Family Physician Phone :
Food Allergies :
Other Allergies :
Does your child use and inhaler? :
What medications is your child on? :
In the event you cannot be reached, do you give permission for a staff member of the Summer Youth Band to act on your behalf should a medical emergency arise while participating in the MMB Summer Youth Band? :
Yes, I give my permission
No, I do NOT give my permission