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:

Optional, but recommended.

Membership Status and Campus Living

I am a:

New Member
Returning Member

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 and Part

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.

Band Camp

I will attend the 2008 Miami University Band Camp.

I will not be attending the 2008 Miami University Band Camp
This must be arranged with David Shaffer prior to August 16, 2008.

I will arrive late to the 2008 Miami Univeristy Band Camp.
This must be arranged with David Shaffer prior to August 16, 2008.
Please indicate below when you will arrive and for what reason.

Medical Information

The following information is used solely in case of emergency during trips, performances, practice, etc.
After filling out the information below, it is NOT necessary to fill out the Emergency Information Form that was mailed to you.

Emergency Contact #1:

	Name:
	Relationship:
	Phone (home):
	Phone (work):

Emergency Contact #2:

	Name:
	Relationship:
	Phone (home):
	Phone (work):

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):