Student Fees Student Name ______________________________________________________ Student Name ______________________________________________________ Student Name ______________________________________________________ Parent Name ____________________________________ Phone # ___________ E-mail address ______________________________________________________________
Marching Band Items Regulation Black Band Shoes – Approx. $25 new; $10 used.
1st yr. band students need to purchase shoes. Returning students
pay for shoes only if they want new shoes or can’t find used shoes that fit. White Gloves - White gloves are worn for the marching season.
Drumline or color guard does not wear gloves. Approx. $3
Additional T-Shirts – One T-shirt is free for each band student.
Additional T-shirts can be ordered. Parents and chaperones often wear
these to show their school spirit at Dowling band events! Please indicate how many additional T-shirts of each size you wish to order below and record the total in the column at right:
Quantity Cost (each) Total Cost Total Due NOW Please return this form by July 15, 2010 I would like to pay this amount toward future fees See reverse for estimated future fees. Please consider paying all or at least a portion of your future fees at this time. Keep in mind that band events are scheduled throughout the school year and transportation, accommodation and meal expenses must be paid as they occur. Student band accounts that are in arrears jeopardize our ability to adhere to the schedule of events. Total Enclosed Related items that are purchased and paid for separately but are shown here for completeness:
• Band/Color Guard Membership Fee - $140 per student (this is part of Dowling Catholic
Registration fees which are paid separately to the Dowling Business Office)
• Black Socks – extending 3 inches above the shoe - purchase these on your own. Band/Color Guard Estimated Future Expenses
ALL BAND/COLOR GUARD MEMBERS (All are required for everyone)
Iowa City /Cedar Rapids Competitions (Sept) Bus and meals
Minnesota Competition (Oct.) Bus and meals
State Contest (Waukee a.m.) / Mid Iowa (Ankeny p.m.) (Oct) Bus and meal
Potential additional in-town competitions School buses
TRIPS/COMPETITIONS
Solo & Group Contests Des Moines Area-Iowa competition
DRUMLINE COMPETITIONS(Required)
JAZZ BAND
Jazz in the Bluffs, Council Bluffs (Feb) Bus, accommodations, meals
UNI Tall Corn Festival, Cedar Falls (Feb) Bus
CONCERT/SYMPHONYBAND Returning students have no fees if they can still wear
last years. There are a limited number of used items.
Please return this form by July 15, 2010 Medical Information Dowling Catholic High School Instrumental Music Department Student name: ___________________________________ Grade: _________ Birth date: ________________ Address: ________________________________________ Home phone: ______________________________ Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: _________ Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: __________ Relative other than those listed above or an emergency contact: Name: ________________________________ Relationship: _____________ Phone: ______________________ Personal physician: _____________________________________ Phone: _______________________________ Personal dentist: ________________________________________ Phone ______________________________ Insurance information Health Insurance: ___________________________________ Policy # ________________________________ Policy holder: _______________________________________ Policy holder birth date: __________________ Medical History Past or present major disease, serious illness, or injury? No___ Yes___ (specify below) Illness, disease, injury: _________________________________________________________ Year: ________ ____Allergy (specify) ______ Contact Lenses ______Kidney Problems Food__________________ ______ Dental problems _______ Seizures Medication_____________ ______ Diabetes _______ Sleep walking Environmental: _________ ______ Fainting _______ Headaches ____ Asthma ______ Heart condition _______ Surgery ____ Bleeding disorder ______ High blood pressure _______ Other Explain items checked: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Any condition that may require special care, education, or diet: ___________________________________________________________________________________________ ___________________________________________________________________________________________
Please return this form by July 15, 2010 ________________________________ (Student’s Name) Release If parents and authorized physician or dentist cannot be reached at the time of emergency and if immediate treatment is urgent in the perception of school authorities, I request, authorize, and will be responsible for necessary emergency medical care. Our physician or dentist may be contacted and is authorized to release requested information. I understand that the chaperones will endeavor to safeguard the health and safety of each student but will, in no way, be held responsible in case of accident or illness. _________________ __________________________________________________________ Parent/Guardian (Must be signed) Over-the-counter Medications Please note, we cannot be responsible for medications given to your student by another student. I authorize chaperones to administer over-the-counter medications as directed in the event of a minor illness (e.g., Tylenol, Ibuprofen, Imodium, Dramamine, Benadryl, cold medications or, Antacids). Yes__________ No_______ Exceptions______________________________________________________________________
_________ _________________________________________________________ Parent/Guardian (Must be signed) Authorization to Administer Medication This must be signed by a parent/guardian to authorize administration of any medication being sent for the student. Medications must be in original labeled containers. Students will be allowed to self-administer asthma inhalers and eye medications. List all medications and non-prescription items such as vitamins and herbal supplements:
Medication No. of doses/day No. of Days _________ _________ ______________ ___________ ________ _________ _________ ______________ ___________ ________ _________ _________ ______________ ___________ ________ I request the prescribed medication to be administered according to the above written directions. ________________ __________________________________________________________ Parent/Guardian Please return this form by July 15, 2010 Uniform Responsibility Agreement Dowling’s cost of a marching band and concert uniform is over $600.00. You are responsible for the care of your uniform! If there is unreasonable and excessive damage to or loss of your uniform, other than normal wear and tear, you will be expected to cover the replacement cost.
• I understand that I will be responsible for the proper care of the Dowling Band Uniform
issued to me/my child. I agree to care for all uniform parts as instructed and return them to the designated area after all performances. This includes the uniform jacket, pants, baldric, hat, gauntlets, and plume. I will also be responsible for my own gloves, socks, and shoes.
• I agree to pay the replacement cost or repair for any unreasonable or excessive damage,
misuse, or loss of the uniform or accessories.
• I agree to pay the cost of any extra cleaning bills due to unreasonable misuse.
Student Signature __________________________________
Date ________________ Student Signature __________________________________
Date ________________ Student Signature __________________________________ Date ________________ Multiple students in same family may sign one form.
Parent Signature __________________________________ Must be signed before uniform isissued Please return this form by July 15, 2010
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