Band Camp Registration

Personal Information

Full Name:

(as listed on your residence hall contract)

Home Address:

City:

State:

Zip Code:

Home Telephone No:

Birthdate:

e.g. 12/15/1984

Current Email Address:

I am a:

New member
Returning member
Former member who will not be returning this year

Reason for not returning:

I will be a:

I will be living:

On-Campus(University Residence Hall)
Off-Campus

Campus Address (if known):

Date of Residence Hall Check-In
(Select N/A if living Off-Campus)

Instrument/Specialty:

Part Assigned last year

1st 2nd 3rd N/A
Please select N/A if not applicable

I will need a university-owned instrument.

I will attend the 2009 Miami University Band Camp.

I will not be attending the 2009 Miami University Band Camp
Note: This must be approved by the Marching Band Staff prior to August 15, 2009.

I will arrive late to the 2009 Miami Univeristy Band Camp.
Note: This must be approved by the Marching Band Staff prior to August 15, 2009.

Please indicate below when you will arrive and for what reason.

The following information is used solely in case of emergency during trips, performances, practice, etc.

Emergency Contact #1:

Emergency Contact #2:

Please list any medications you are taking:

Please specify any allergies, dietary restrictions, or other medical conditions you have (i.e. bee stings, diabetes, etc.):

Please list any other factors that might restrict your participation:

Medical Insurer:

	Insurance Company Name:
	Address:
	Group/Policy Number:
	Certificate/Individual Number (how the insurance company identifies you - could be social security number):