Dimmitt ISD

Band

HANDBOOK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2004-2005

               

 


PREFACE

 

The purpose of this handbook is to provide information about the band program in the Dimmitt Independent School District.  It will be of value to all members of the program and their families if proper attention is given.  The handbook contains a wealth of information to help you understand what it means to be a member of this award winning organization.  It is designed to help you become more familiar with the program as it is today and as the directors want it to develop.  This handbook is practical as well as informational.  The band program rules and regulations are also specified.  Students should share this handbook with their parents.  Parents, please complete, remove and return the forms at the end of the handbook.

 

 

 

 

PHILOSOPHY

 

It is a part of the philosophy of the Dimmitt ISD that it exists primarily to educate the youth and that it is the chief agency in developing the intellectual powers of its’ students.  Among the objectives of the Dimmitt ISD is the desire to encourage the creativeness and development of special aptitudes and talents as well as to instill an appreciation for and an awareness of the value of the visual and performing arts.

 

Music study furthers the total growth of students in a quickly developing society that stresses scientific achievement, material wealth, and extreme specialization in various fields of endeavor.  Music, as an integral part of the school curriculum, contributes to the overall balance of the student’s educational experience.  It is the purpose of music to serve students first as an art form; and second, to provide an opportunity for recognition, satisfaction, and enjoyment through a worthwhile experience.  It is the further purpose of music to discover innate talent and develop clear-thinking individuals with well-developed problem solving skills, good work habits, and wholesome ideas of conduct, strength of character, mature citizenship, and pride in being part of a group activity.

 

To implement these basic philosophies, Dimmitt ISD offers band to all students who desire to participate in an organization that will challenge their abilities.  Band at Dimmitt is performance and activity oriented.  It is our belief that students become excited and involved in music through the challenge of quality performance.  A direct result of this motivation will be an increased interest in other areas of music as well.  The band program is organized to serve the musical needs and interests of these students.  Competitive activities are strongly emphasized and utilized as a key motivating factor in the band program.

 

 

 

 

AUTHORIZATION FORMS

 

Medical Authorization and Consent and Understanding forms must be filled out and returned to the band director by the pre-set deadline.  These forms are included in the back of the handbook.

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTITUDE AND DISCIPLINE

 

The greatest single factor that will determine the success of any individual and the group as a whole is attitude.  It takes intense dedication to reach well thought-out goals.  Students must learn to discipline themselves to practice daily.  To improve individually is to improve the group. 

 

Not all students are in band for the same reasons.  Some are there for the pure joy of the musical experience.  Others are in band for the reward of the performance.  Many participate simply for the social activities.  Poor attitudes, while evident in only a few students, can have a major detrimental impact on the entire organization.  Regardless of motivation, each student is expected to participate wholly.  All motivational types are welcome if the accompanying attitude allows the student to diligently strive to improve both individually and as a group member.

 

Because of the nature of all group activities, discipline must be strict.  Our goal is to promote a positive learning environment for every student, regardless of ability level or experience.  Band students and parents must be willing to accept the ideals, principles, and rules of the organization.  Because the band is constantly under public scrutiny, we must always be aware of the importance of appropriate behavior.  The student must remember that he/she represents the organization, school, and community at every performance or public appearance.  Any misconduct casts a negative reflection on our school and community and may well undo the good works of hundreds of loyal students.

 

Good bands are built on discipline; but let us first agree on the definition of discipline.  Discipline is order.  Discipline is respect.  There is order in all things physical or material, as well as all things spiritual or intellectual.  With order comes attainment of things worthwhile.  While everyone agrees that order is essential, we will all prioritize differently.  We must also respect the differences among our band members.  Respect each other’s opinions and property and we can achieve order without chaos.

 

The goal of the faculty of Dimmitt ISD is to prepare students through a variety of training methods to handle most situations.  Discipline is an important part of our band program.  We do not punish students for mistakes.  Discipline and punishment are two different things.  When a transgression occurs, the student needs to be trained, not necessarily punished.  When most people make mistakes, they do not intentionally break rules.  If there are honest mistakes, then corrective training and behavior modification will be implemented.  If a student willingly, knowingly and intentionally violates the precepts our organization functions under, then immediate punishment will accompany the training program instituted.  Everyone makes mistakes.  We will never punish mistakes without first re-training the proper method of handling any given situation.  Parents will be kept informed of most disciplinary actions involving their child. 

 

 

 

 


RULES OF CONDUCT

 

As a member of the band, you are a part of one of the school district’s most important organizations.  Therefore, the success of the band will depend on the loyalty, cooperation and dedication of each and every member.  The guidelines outlined in the following pages are simple, sound, and easy to follow.  In keeping these rules, you are meeting an obligation that will help make our band successful.

 

Each band member should carefully read and adhere to the following:

 

·         Any behavior that causes a disruption or interferes with the education process will not be tolerated.

·         Possession, sale or use of narcotics, drugs, alcohol, tobacco or other controlled substance will be grounds for immediate removal from the program and referral to the administration.

·         Possession of any weapon, dangerous instrument or object that could be reasonably considered a weapon will be grounds for immediate removal from the program and referral to the administration.

·         Be prepared for rehearsal.  Prepare your music ahead of time.  Practice is a must.  Have all necessary materials:  instrument, music, drill charts, reeds, mutes, PENCIL, valve oil, sticks, mallets, etc. 

·         Conduct which does not display respect for each other will not be tolerated.

·         Any type of discrimination will result in immediate disciplinary action.

·         Rehearsal time is at a premium.  Please, be ready to begin rehearsals at the appointed time.  Early is on time; on time is late.

·         Each of us must be respectful of our facilities.  Therefore, do not bring food, drink, candy or gum into the band hall. 

·         The band hall is open to students whenever a director is on campus.  We want you to be at home in our facilities.  The director’s offices, however, are places to conduct business.  Please, do not enter without permission.     

·         Your instruments are very expensive.  Do not touch any other instruments.

·         The band functions as a family.  Ask all non-band members to remain outside.  We have many valuable instruments in the band hall.  Your friends do not know the proper way to handle or care for musical instruments.

·         The band will provide you with storage space for your instrument.  Your space may be inspected or searched by the faculty at any time.  It is your responsibility to maintain sanitary conditions in your area.

 

Methods of training or disciplining the student will be one or more items from the following:

 

                1)             written report or additional research in the field of music or related to the                                                                disciplinary problem

                2)             after school detention supervised by the director not to exceed one hour

                3)             immediate corrective action

                4)             loss of third quarter privileges at football games

                5)             loss of free time on activity trips

                6)             one on one counseling with the director to institute a discipline                                                                                management plan

                7)             parent telephone conference

                8)             parent conference at school

                9)             administrative involvement

                10)           removal from group activities

                11)           cleaning practice facilities

12)                additional physical training

 

The directors will attempt to keep parents informed of any disciplinary action concerning your child.  Minor infractions might not require parental involvement.


ATTENDANCE

 

Attendance is required at all rehearsals and performances.  Excused absences must be pre-approved by the director.

 

High School -  All rehearsal time is at a premium.  During football season, marching rehearsals will be held Monday and Tuesday, 6:00 – 8:30pm.  Music rehearsals will be held daily in class.  There will be a brief run-through of the marching show at 7:15am each Wednesday and Thursday morning.  Transportation to the Middle School will be provided for all 8th grade marchers.  Missed rehearsals diminish the opportunity for the band to perform at the level of our capability.  Everyone must attend all rehearsals for us to reach our potential.  If there is an unavoidable conflict, it is preferable to miss playing rehearsal instead of marching rehearsal.  All absences should be cleared through the director before the missed rehearsal.  The director may call additional rehearsals as needed during the marching season.  At least one-week notice will be given for any extra rehearsals.  Earning a P.E. credit waiver is contingent on successfully participating in marching band.  Attendance is required.

 

During Concert season, each section will have one, 1-hour sectional rehearsal outside of school time each week in preparation for contest.  These will be planned to fit student schedules.  Sectionals will begin after the Christmas break.

 

Chronically poor attendance will be sufficient grounds to be removed from a specific performance.  A part of your grade is based on daily work.  If you are not here, you cannot receive a grade. 

 

7th & 8th grade – During football season we will concentrate on developing marching and playing skills.  8th grade students will be expected to perform with the high school marching band.  If assigned, your attendance is required at all after school rehearsals.  The Jr. High Band will perform at all pep rallies. 

 

During Concert season, each section will have one, 1-hour sectional rehearsal outside of school time each week in preparation for contest.  These will be planned to fit student schedules.  Sectionals will begin after the Christmas break.

 

Chronically poor attendance will be sufficient grounds to be removed from a specific performance.  A part of your grade is based on daily work.  If you are not here, you cannot receive a grade. 

 

5th and 6th Grade – In order to develop instrumental skills you must have daily repetition.  Class time will be spent playing your instrument.  You must be prepared for class.  You must reinforce instruction with individual practice.  You are expected to practice a minimum of 15 minutes per day.  Weekly practice cards, signed by the parent, will be turned in the first day of each week.  This assignment will not be accepted late accept in the case of student absence.

 

We will perform in concert during the months of December and May.  Participation in Solo & Ensemble and Festival Contests are subject to grade eligibility.

 

Chronically poor attendance will be sufficient grounds to be removed from a specific performance.  A part of your grade is based on daily work.  If you are not here, you cannot receive a grade. 

 

ATTENDANCE IS REQUIRED AT ALL PERFORMANCES.  An unexcused absence from a performance will result in a “0” for the performance grade and is sufficient reason for dismissal from the performing band.  Excused absences must be pre-approved by the director.  Make-up work will be assigned in order to credit the student with the appropriate performance grade.

 

 

 

 

 

 

GRADING PROCEDURE

 

Grades consist of three categories, each counting equally: 

 

·         Daily grade - having the proper supplies for rehearsal, general attitude and participation in required rehearsals.  This does include both class and after school rehearsals.

 

·         Performances - all regularly scheduled, required performances.

 

·         Tests - assigned playing tests.  Due to the number of students per class, it is not feasible to hear each student individually during every class period.  Therefore, some assigned tests will be recorded by the student and turned in to the director.  If your tape is turned in before the due date, an additional five points will be awarded to the test results.  Five extra points can also be earned by performing your test with a metronome.  If a test is turned in late, there will be a ten-point deduction for each day late.  Tape recorders and metronomes are available for student use.  You must rewind your own tapes; the director will not grade tapes that are not rewound.

 

 

TRY-OUTS and CHALLENGES

 

Try-outs or auditions are an integral part of the instrumental music world from the earliest stage of training to the highest level of performance.  Competitive activities are strongly emphasized in the Dimmitt band program.  The band department, therefore, maintains a system of competitive try-outs, tests and challenges to further instrumental education and to evaluate work done by the individual student.  Try-outs will be scheduled each year to determine music part placement only. The audition is to correctly assign the students to the appropriate part with other students of approximately the same ability level.  By being assigned to the appropriate part, every student can succeed.  The level of performance expected of each student is the same.  However, the difficulty of the music may vary.  EVERY STUDENT that plays an audition for the director WILL BE IN BAND.

 

Following all tests or try-outs, any student may challenge the student placed immediately ahead of them.  The challenge procedure is as follows:

               

1.             Both students report to the director.

                2.             The director indicates challenge materials and time.

3.             Challenge material will include scales, arpeggios, and music from the folder of the person being challenged.

                4.             At the appointed time, the director will hear the challenge.  The director                                                  will not know which students are performing until after the challenge is                                                       resolved.

                5.             Students may immediately re-challenge, following the same procedure.

                6.             As contests approach, challenges will be suspended.

 

All-Region, All-Area, All-State, and Solo & Ensemble competitions are important in encouraging the individual development of our students.  Therefore, students who successfully participate in these ‘extra’ activities will be rewarded within our band program with preferential chair placement and leadership opportunities.

 

 

ELIGIBILITY

 

Adherence to the UIL No Pass / No Play rule will be closely monitored.  On a six-week cycle, eligibility will be effected every three weeks.  Therefore, it is imperative that students remain diligent in their studies.  YOU WILL NOT BE ALLOWED TO PARTICIPATE IN ANY EXTRA-CURRICULAR PERFORMANCE IF YOU HAVE FAILED A CLASS.  Pass your classes!

 

PRIVATE LESSONS

 

In order to move our program forward, a private lesson program is in place to allow any student to study privately with a professional musician accomplished on his/her own instrument.  The directors encourage every student to take advantage of this program.  Studies have shown that students studying privately far exceed those only receiving instruction in class.  Students taking private lessons tend to achieve higher placing in individual competition.  There are a limited number of scholarships available provided by the Band Boosters.  These scholarships will be granted based upon demonstrated need.  An application is attached and should be turned in to the director as soon as possible.  Those students desiring private lessons not granted scholarships will be expected to pre-pay for all lessons each month.  Payments should be made through the directors to the Band Boosters.  Lesson cost is $10.00 per half hour per week.  All private instruction will occur outside of school hours.

 

 

UNIFORMS

 

Uniforms will be issued only to those members meeting the criteria set by the directors.  Abuse of and/or failure to obey these requirements will result in the student losing the privilege of wearing our uniform.  Any damage, other than normal wear, or loss of uniform parts will be charged to the students.  Uniforms will be issued prior to each season.  Cords will be awarded to those students successfully performing their contest show music from memory for a director.  Band students must furnish their own set of approved marching shoes, gloves and a band shirt.  (Shoes, gloves and t-shirts will be ordered during registration.) There will be a one-time $25 uniform cleaning fee collected during registration.   Damage to uniforms caused by either neglect or intent will be charged to the student.

 

 

MUSIC

 

Music, which is necessary for participation in class-related activities, will be provided for you.  This includes music for marching season, concert season, All-Region and Solo & Ensemble.  You are required to take care of this music.  The student must pay for lost or damaged music.  You are responsible for private lesson music. 

 

 

SCHOOL INSTRUMENTS AND EQUIPMENT

 

The Dimmitt band program owns a limited number of instruments.  These instruments are assigned to the students on the basis of ability and need.  It is the responsibility of the student to return the instrument in as good a condition as when it was issued.  Students must report any damage or necessary repair immediately to the band director regardless of the cause.  Unnecessary and expensive maintenance can be avoided by making sure the instrument is cleaned regularly.  Periodic unannounced inspections will be held to insure proper care is given.  Failure to properly care for school instruments will void the privilege of using them.  Students using school owned instruments would be required to pay a $25.00 maintenance fee each semester.  This fee will be collected during registration.

 

 

ASSISTANTS / INSTRUCTORS / CLINICIANS

 

At times the band will have assistants, instructors, or clinicians helping with the program.  These are professionals interviewed and selected by the director.  All assistants, instructors, and clinicians will be treated with the same respect and attentiveness as the band directors.

 

 

 

 

 

BAND TRIPS

 

·         All band trips will have received prior approval of the school administration.

·         The bus will leave on time unless unavoidably delayed.  It is the responsibility of the student to be on time.  The bus will not wait for anyone.

·         One or more adult chaperones will be on each bus.

·         The bus is to be treated with care and all trash must be placed in the receptacle provided.

·         No one will leave the group for any reason without director approval.  Anyone leaving with approval must travel in groups of at least 3.

·         Parents should meet their child at the appointed time at the band hall.  The directors will never leave a student at school alone.  Therefore, do not make the directors wait for your ride.  PLAN ahead.

·         Smoking, drinking, drug use, or the possession of such material will not be tolerated.  Violators will be prosecuted under both district rules and criminal law.

·         Public displays of affection are inappropriate.  While everyone understands the desire for a sharing of affection, there are times where such behavior could be offensive.

·         Students will travel to a band commitment as a group on the transportation provided.  There will be no exceptions to this policy. 

·         Students will be expected to return on the transportation provided as well.  Under extenuating circumstances, exceptions will be made on a case-by-case basis.  Students can only be released to their own parent or guardian.  Written requests must be approved and filed with the principal’s office and band director before the band leaves Dimmitt ISD.

·         Do not apply any perfumed product on a bus or in the band hall.  Some people are sensitive to strong aromas especially in closed in spaces.  Some perfumed products include: hair spray, hand lotion, cologne, after-shave, perfume, baby powder, etc.

·         To protect the lives of the students it is necessary that the bus drivers be able to concentrate on their driving.  Therefore, there shall be no shouting, singing, clapping, etc., or any other loud noises that might distract the driver. 

·         If you wish to listen to pre-recorded music, please bring headphones.  Everyone does not have the same taste in music.  You will not be allowed to listen to music without headphones.

·         If the band is traveling on charter buses equipped with televisions and VCR’s, movies, pg-13 or lower, must be approved by the director or adult chaperone on the bus.

·         Everyone must remain seated, facing forward while the bus is in motion.

·         Do not bring food, drink, candy or gum onto the bus unless specifically approved by the director.  There will be occasions which dictate eating on the buses.  The directors will specify these.

·         Profanity is offensive and will not be tolerated.  It is imperative that we be respectful of each other.

·         Any jokes, comments or observations with sexual overtones will be interpreted as sexual harassment and dealt with accordingly.

 

These guidelines are not meant to prevent students from having fun.  They are designed to allow everyone the same opportunity to have a good time.  If everyone adheres to these basic guidelines, no one will have a negative experience as we travel.  These rules give everyone the freedom to enjoy the experience without others infringing on your rights.

 

 

 

 

 

 

 

 

 

 

 

 

 

FOOTBALL GAMES

 

A detailed itinerary will be made available prior to all performances.  For all games, the band will meet in block formation in the band hall at the time specified.  Attendance will be taken at the time indicated on the itinerary.  Anyone that is late will lose third quarter privileges and receive a lower grade for the performance.  At that time, the band director will conduct a brief uniform inspection to insure proper care, maintenance, fit and wear of the uniform.  If we are not traveling in uniform, a brief inventory inspection will be held to insure that no parts are forgotten.  All uniform parts must be present at inspection.  If a student has discrepancies, their grade for the performance will suffer and they may not be allowed to perform.  Following inspection, the students will load the bus by grade, seniors first.  Students will ride on their assigned bus only.  The uniform coat may only be removed if placed on a hanger if we are traveling in uniform.  If we are not traveling in uniform, modest travel clothing may be worn.  The current band t-shirt will be worn under the uniform at all times.  When the band is traveling out of uniform, we will wear blue jeans; the current years band t-shirt and tennis shoes.  There are no exceptions to this policy.  This requirement is for safety and security purposes.  Uniform attire allows our students to be identified immediately.

 

Upon arriving at our destination, all students must remain in their seats until directed to do otherwise.  After leaving the bus, students must get their instruments and immediately seek the Drum Major and line up in block formation.  After entering the stadium, we will sit in the stands in the same block order as used for inspection.  NO ONE WILL PLAY WITHOUT EXPRESS INSTRUCTIONS FROM THE BAND DIRECTOR.  Once in the stands, the percussion will be given time to complete warm-ups.  All warm-ups must be completed with everyone in their assigned seats no later than 30 minutes prior to kick off.  At no time before, during or after the game will any individual or section play without director approval.  The percussion section will be allowed to play cadences and street beats throughout the game, with director approval.  In order to assist the football team, we will not play while our team has the ball.  The sounds distract the players.  We will play while on defense.  Students must be prepared at all times to play the Fight Song.  In order to assure this, everyone must remain in his or her assigned place.  Football games are fun, but we must always remember that the band is constantly in the public eye.  Your behavior in the stands can never reflect negatively on the program, school, or yourselves.  Approximately halfway through the second quarter, we will move out of the stands to complete warm-ups and focus for the performance.    Immediately following the performance everyone must return to his or her place in the stands.  When all students are back in place, you will be dismissed for the third quarter.  All students will have the third quarter off unless directed by the band director.  No one will play or perform in any way during the third quarter.  When the clock reaches “0:00” you must be in place prepared to play.  If you are late in returning, you will lose future third quarter privileges.  At no time will food or drink be brought into the stands.  We must keep all food and drink out of the stands in order to protect the instruments and uniforms.

 


PERSONAL APPEARANCE

 

The personal appearance of the individual is important.  In no way is this program trying to suppress the individuality of the members.  However, all audience focus must be on the group, not the individual.  Therefore, when in uniform, the following guidelines will be exacted:

 

1.             No jewelry...watches, rings, earrings, body piercing, necklaces.                                                 The only exceptions will be senior rings and religious necklaces                                    worn under the clothing.

 

2.             All band members (male and female) will wear their hair off the                                                   collar.  Hair will be worn pulled back in ponytails or females may                                                                wear a French braid.  All hair will be worn inside the hat for                                                                              marching band.  Distracting hair colors violate district policy.

 

3.             When the uniform is designated to be worn, it is to be worn in its entirety.  The                             jacket may not be unzipped or removed and the suspenders must be worn.  Hats and gloves may be removed with director permission.

 

4.             Makeup will not be worn in uniform.  This is to insure uniformity of appearance and to prevent makeup form getting on the uniforms.

 

5.             Color Guard makeup will be specified by the director.

 

Attire for travel and rehearsal must be conservative and modest and will always include the current years band t-shirt.  The director understands the physical nature of marching rehearsal.  Rehearsal clothing should accommodate ease of movement and comfort while maintaining proper decorum.  Tennis/running shoes are to be worn for all marching rehearsals.  Under the uniform students should wear their band t-shirt and shorts.  We will dress in groups.  Under garments must not be used as outer garments.

 


BAND ORGANIZATION

 

Administration:    Superintendent, Principal, Assistant Principal, Band Director, Assistant Band Director

 

Student Leaders: 

 

Drum Major: selected by the Band Director during a try-out each spring for the following year.  These individuals assume a leadership role in all marching performances and rehearsals of the band.  Information concerning qualifications and try-outs may be obtained from the band director.

 

Band President:    elected by the band students each spring for the following year.  The Band President must be a senior.  This individual is the highest elected office representing the band.  The Band President must uphold the highest traditions and spirit of the band.  The Band President also coordinates all other student officers for the band as well as promotes all band activities, social, educational, etc.

 

Vice President:      elected by the band students each spring for the following year.  The Vice President must be a Junior or Senior.  This student assists the President as needed.

 

Secretary: Appointed by the director each spring for the following year.  The Secretary is responsible for maintaining accurate attendance records and representing the band at school and community functions.

 

Librarian: elected by the band students each spring for the following year.  Librarian will assist with the issue of all necessary music. 

 

Historian:  elected by the students each spring for the following year.  The Historian must be a senior.  The Historian will                 maintain a photographic record of all band activities for the year.  Preparing the video for the banquet is the primary responsibility of the Historian.

 

Class Representatives:        elected by the band students each spring for the following year.  Class Representatives serve on the Band Council for the entire year.

               

Section Leaders:   selected by the director based on ability, experience, interpersonal skills as well as teaching skills. With director approval, a section leader may appoint an assistant in larger sections.  Section leaders are not considered officers.

 

All student leaders must maintain eligibility in order to retain office.  Elected officers will meet all specified responsibilities and assist the director as needed.  Appointed officers and section leaders will be responsible for the musical and marching performances of their sections and will assist the director as requested.  All student leaders will attend a mini-camp with the director prior to summer band.  The purpose of this will be to set goals, agendas, discuss marching techniques, design the band T-shirt, and other objectives as needed.  Any student leader failing to meet the duties of their position can be placed on probation or replaced. 

 

SUMMARY

 

It is the wish of the staff at Dimmitt ISD for every student to have the opportunity to participate in band if they so desire.  We welcome all students, regardless of past musical experience to our classes.  We will teach those wanting to learn.  Our band can only grow and improve if we work together, helping each other overcome difficulties and sharing the joy of our successes.  The only way a student can fail band, is to fail to try.  The only way band can fail a student is if we all fail to accept our differences, strengths and weaknesses.  It is our goal that each student enrolled in one of the band classes will have a rewarding and worthwhile musical experience.  When there are questions or concerns, please do not hesitate to call and discuss them with your band directors.  The telephone number in the band hall is

806-647-3108 (MS) or 806-647-3105 (HS).


AUTHORIZATION FOR MEDICAL TREATMENT

AND RELEASE OF LIABILITY

 

I have given my consent for my child _________________________________ to travel and take part in any activities sponsored by the Dimmitt High School Band.

 

I understand that these activities will be closely supervised by the directors and responsible adults and that everything possible will be done to ensure the safety of my child.  I also recognize that accidents and/or illnesses occur.  I hereby release the Dimmitt High School and its faculty, supervisors, and boosters in charge of activities of any and all responsibility or blame for any accident, illness or injury received by my child during these trips.

 

In the event of an accident, illness or injury, I request that I be contacted immediately and before any medical and/or dental treatment is administered.  However, if I cannot be reached immediately at the number shown below, I recognize that it may be necessary to proceed with medical and/or dental treatment for the well being of my child.  In such an emergency where I cannot be contacted, I hereby authorize the attending physician, surgeon, and/or dentist to exercise his/her personal judgment as determined to be necessary for the health and/or safety of my child, and to proceed with such treatment as though I were personally there giving him/her my full consent and support.

 

 

My emergency number (or numbers) __________________________________________

 

I certify that I am the parent or legal guardian of the minor child named above and that I have health insurance as follows:

 

Company _______________________________________________________________

 

Name of Policy Holder _____________________________________________________

 

Policy Number ___________________________________________________________

 

Policy Holder’s Signature ___________________________________________________