SMHS MUSIC DEPARTMENT CONSENT FORM

Transcription

1 SMHS MUSIC DEPARTMENT CONSENT FORM STUDENT'S LAST NAME DATE OF BIRTH FIRST NAME STUDENT ID# (Please circle all applicable ensembles) Enrolled in: Marching Band Wind Ensemble Concert Band Jazz Band Symphony Orchestra String Orchestra Winter Drum Line Winter Color Guard Name of Parent(s) or Legal Guardian(s) Address City Zip Home # Mother /Guardian Cell Mother/Guardian Student Cell Father/Guardian Cell Father/Guardian ALL INFORMATION MUST BE COMPLETED & RETURNED TO THE SMHS MUSIC OFFICE BY AUGUST 27: 1) PERMISSION TO TRAVEL 2) POWER OF ATTORNEY 3) CHAPERONE RELEASE 4) AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR 5) NAME AND LIKENESS RELEASE PAGE 1 OF 6

2 1) PERMISSION TO TRAVEL Please be advised that age has our permission to travel with the San Marino High School Marching Band, Color Guard, Concert Band, Wind Ensemble, Orchestra(s), Jazz Band, and/or Drum Line starting at 3:00 p.m. on Monday, August 13, 2018 through 9:00 p.m. on May 31, We understand that during that time the groups of the Instrumental Music Department will be traveling throughout Southern California at different performing events (see Calendar addendum). 2) POWER OF ATTORNEY The undersigned certifies that he or she: is the Parent or Guardian of ; that the child is a student of San Marino High School, Los Angeles County, California; will be traveling with the San Marino High School Marching Band, Color Guard, Concert Band, Wind Ensemble, Orchestra(s) Jazz Band, and/or Drum Line starting on Monday, August 13, 2018 through 9:00 p.m. on May 31, 2019; and, that Shota Horikawa, SMHS Music Director, or his designee(s), will be in charge of the student group(s) during such trips, lasting from the above stated dates. If parents cannot be immediately contacted, the undersigned does hereby grant full Power of Attorney to Shota Horikawa, or his designee(s), in the event of accident or illness to his or her child at any time from the commencement to the termination of such trip, including, without restriction, the generality of the foregoing: the selection of physician or physicians, provisions for hospitalization and the consent to any operation or any kind of medical treatment for said child as fully as the undersigned parent of such child might do if personally present, hereby fully ratifying all that said person to whom this Power of Attorney is granted may do in regard to the foregoing. 3) HOLD HARMLESS RELEASE I/We hereby give my permission for my son/daughter _ to travel with the San Marino High School Marching, Color Guard, Band Concert Band, Wind Ensemble, Orchestra(s), Jazz Band, and/or Drum Line starting on Monday, August 13, 2018 through 9:00 p.m. on May 31, I/We do hereby hold harmless and release Shota Horikawa, SMHS Music Director or designee(s) and/or chaperones (to be named), and the San Marino Unified School District from any liability arising from any musical event, performance and or competition sanctioned by the San Marino High Instrumental Music Department. PAGE 2 OF 6

3 4) AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR I/We, the undersigned, Parent(s) or Guardian(s) of, a minor, do hereby authorize: 1. Shota Horikawa, SMHS Music Director 2. Andrew Arce, Color Guard Instructor 3. Scott Tanaka, Percussion Instructor 4. Jazz instructor (to be named) 5. Chaperones of the SMHS Instrumental Music Department: (to be named) as agents for the undersigned to consent to any x-ray examination, anesthetic, medical, surgical diagnosis or treatment, and/or hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable; and neither said agent or any organization involved assumes any financial responsibility for exercising this action. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain in effect until revoked in writing and delivered to said agent(s). Doctor s Name Phone # Health Insurer Name Group Name/Policy # List all allergies/medications/dietary restrictions: PAGE 3 OF 6

4 5) NAME AND LIKENESS RELEASE By enrolling in the Instrumental Music Department program(s) at San Marino High School (SMHS), I/we acknowledge and agree that my son or daughter may be filmed, taped, photographed or otherwise recorded while at SMHS and/or participating in activities relating to the SMHS Instrumental Music Department. I/We, therefore, agree that my son s or daughter s name, likeness, and/or image recorded while enrolled at SMHS may be used by the Music Department in connection with publicity and promotion for the SMHS Music Department in any media or format, throughout the world. I/We have read and understood and agree to the: 1) PERMISSION TO TRAVEL; 2) POWER OF ATTORNEY; 3) CHAPERONE RELEASE; 4) AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR; AND 5) NAME AND LIKENESS RELEASE contained in this document. Signature of Father or Legal Guardian Signature of Mother or Legal Guardian Date Date Address City Zip PAGE 4 OF 6

5 ADDENDUM A SMHS TITAN MARCHING BAND/PEP BAND COMPETITION & PERFORMANCE DATES (AS OF 7/30/2018) SMHS Varsity Football Games (Fridays, 7 p.m.). Home games only except Playoffs which are voluntary and dates T.B.D. Note: Football Pre-game Band Dinner (Home games only), 3:30-5:30 p.m. Friday, August 17 - vs. Pasadena (Home) Friday, August 24 - vs. Northview (Home) Friday, September 7 - vs. Sante Fe (Home) Friday, September 21 - vs Newport Harbor (Home) Friday, September 28 - vs. South Pasadena (Home). Homecoming Parade 3:15pm, Titan Tailgate 6pm November/December - Subject to CIF Playoff schedule Marching Band Competitions (Saturdays, Time to be confirmed) October 6 Warren Field Tournament (Warren High School, Downey) October 20 West Ranch Field Show (West Ranch HS, Santa Clarita) October 27 Western Band Association Super Show (Long Beach City College, LB) November 3 - Los Altos Field Show (Los Altos HS, Hacienda Heights) November 10 - Savanna Field Show (Savanna High School, Anaheim) November 17 - SCSBOA Championships (if qualified) BASKETBALL GAME - PEP BANDS (Attendees TBD Organized by Band Council) SMHS Boys Varsity Basketball Games (Home - 5:15 p.m. or 7 p.m.) January 8 Tuesday - vs. Monrovia 5:15pm January 11 Friday - vs. Temple City 5:15pm January 26 Saturday - vs. Blair 7:00pm January 29 Tuesday - vs. La Canada 7:00pm SMHS Girls Varsity Basketball Games (Home 5:15 or 7 p.m.) January 8 Tuesday vs Monrovia 7:00pm January 11 Friday vs. Temple City 7:00pm January 26 Tuesday vs. La Canada 5:15pm Carver/Valentine/HMS Showcase Week of AUG. 27 (Tentative) PAGE 5 OF 6

6 Other Important Dates: (all dates/times/locations are subject to change) PTAffiliates Marching Band 2018 Summer Courses June 4 - July Marching Band Camp July 30 - August 10, 1-9 p.m. Marching Band Parent Meeting Fri. Aug 10, 7p.m. Marching Band Pre-Season Performance Fri. Aug 10, 8-9 p.m. Marching Band Photo Day Tuesday, September 11, 3-5 p.m. Instrumental Music Dept. (non-marching Band) Mandatory Parent Info Meeting Wed., Sept 12, 7 p.m. Marching Band Camp Saturday, September 8, 9 a.m.- 5 p.m. Winter Drumline Mandatory Parent Info Meeting Monday, Sep 17, 7-8 p.m. Marching Band Camp Saturday, September 15, 9 a.m.- 5 p.m. Marching Band Camp Saturday, September 22, 9 a.m.- 5 p.m Winter Drumline Auditions TBD Homecoming Parade Friday, Sept 28, 3-4 pm Marching Band Pre-Football Dinner on Campus Friday, Sept 28, 4-5 pm Winter Color Guard Auditions Week Tuesday-Friday: November 27, 28, 29,30. All 3:30-5:30pm. Marching Band Banquet for Students Friday, November 30, 6-9 p.m. - TBC Winter Color Guard Mandatory Parent Info Meeting Friday, November 30, 6-7 p.m. Winter Concert Wednesday December 12, 7 p.m. Instrumental Music HMS Parent Info Meeting Wednesday, February 27, 7pm. Wind Ensemble/Symphonic Orchestra Photo Day Wednesday, February 6, 3-5 p.m. Concert Band/String Orchestra/Jazz Band Photo Day Thursday, February 7, 3-5 p.m. Wind Ensemble/Orchestra/Concert Band/Jazz Band Festival Dates March, date TBD (likely within first two weeks of March) Spring Concert Friday, March 29, 7-8:30 p.m. ARTS Rocks Saturday, February 2, 11a.m. - 5 p.m. Spring Break - Monday - Friday, March Jazz Concert Tuesday, April 9, 7-8 p.m. location to be confirmed. VAPA 8 th Grade HMS Parent Night Thursday, April 18, 6-8 Winter Drumline/Winter Color Guard Community Showcase Saturday, April 20th, 6-9pm Pops Concert Friday, May 3, 7-9 p.m. Marching Band Parent Information Meeting Monday, May 6, 7 p.m Instrumental Music Dept. Awards Banquet Wednesday May 22, 6-9 p.m. Venue to be confirmed. Last Day of School Thursday, May 30 SMHS Graduation (Wind Ensemble/Concert Band) Friday, May 31, 7-8 p.m. PTAffiliates Marching Band 2018 Summer Courses June 3-July 12 Summer Vacation from all Instrumental Music programs July 13-July Band Camp July 29-August 9, 1-9 p.m. PAGE 6 OF 6