band camp packet instructions - Corona del Sol Band Boosters

Corona del Sol Aztec Marching Band
BAND CAMP PACKET INSTRUCTIONS
**PLEASE READ**
All essential paperwork is in this packet.
Everything must be filled out AS COMPLETELY AS POSSIBLE. Your Band Camp packet should include:
1.
WELCOME LETTER, ESTIMATED COSTS, PACKING LIST & DIRECTIONS TO PINE SUMMIT CAMP for
participation in the Marching Band, and information about BAND CAMP.
2.
(GREEN) DISCIPLINE AGREEMENT/INFORMATION + Payment for Band Camp.
a. (EARLY COST) $400 if postmarked/received on or before May 6
b. $425 if received between May 7 to May 18
c. A late fee of $50 will be charged if received after May 19 (total of $475).
d. ALL FORMS are due by May 18 (including medical and physical forms)
e. Checks made payable to Corona del Sol.
f. The Discipline Agreement & Medication Form must be filled out online at cdsband.org
g. BAND CAMP can be paid with TAX CREDIT. If you are paying by this option, be sure to fill
out the enclosed Tax Credit Donation Form. You can claim up to $400 and receive a refund
on your state taxes for the amount donated!
3.
PHYSICAL CARD with proof of physical examination given on or after January 1, 2015. Please complete
and fill out the side of the form with your name and student ID number. The physical portion must be
completed by May 18 – mail in as soon as physical is complete. This is a requirement to bring the band
in alignment with district and AIA athletic/activity practices. STUDENTS CANNOT ATTEND CAMP
WITHOUT THEIR PHYSICAL CARD. If you plan on participating in athletics at Corona – make a copy of
this Physical form to turn in to the Athletic office. Please have your doctor fill out the required sports
physical form. You may also use Physico Health Assessments, CVS Pharmacy or Walgreens (they have a
“Minute Clinic”), or your doctor’s office. All physicals must be completed and turned in by MAY 18.
4.
EMERGENCY MEDICAL CARD (GOLD PAPER) must be COMPLETE by May 18. Emergency cards do
not need to be notarized – a parent can fill this out in its entirety – it must be signed in person with a
school official present, however. Again, we need this medical information in case a student is injured,
so STUDENTS CANNOT ATTEND CAMP WITHOUT AN EMERGENCY FORM. Emergency Medical
Forms must be completed and sent in by MAY 18.
5.
(PINK) BAND BOOSTER MEMBERSHIP APPLICATION – You can either complete & send in with your
Band Camp forms, or send to address on the form. Either way please pay with a separate check made
payable to CDS Band Boosters and staple it to that form.
6.
(PURPLE) CAMP FAMILY BBQ ORDER FORM - You can send this form in with your other Band Camp
forms. Please pay with a separate check made payable to CDS Band Boosters and staple it to the BBQ
form.
CORONA DEL SOL BAND CAMP 2015
Congratulations!
You have been accepted into the 2015 Aztec Marching Band and invited to
the 2015 Band Camp! As a selected participant, you will find this to be one
of the finest marching band experiences in the Southwest United States.
With this honor comes a great deal of responsibility. Please check the
Tentative Schedule and Estimated Costs Sheet. Make sure that you can
meet all of the season’s commitments!
Band camp activities begin on July 19th with our trip to Prescott and end on July 25th with a concert in the
cool pines of Pine Summit Camp. Here is the list of dates for our pre-band camp activities:
• Summer Rehearsals: These are required – Please refer to the online Calendar as there are different
dates for woodwind, brass, percussion, and color guard. If you are in town, please be there on time!
If you are on vacation with your family, you must excuse the absence with your instructors
AHEAD OF TIME. Failure to contact your instructors PRIOR to the rehearsal could result in
suspension or removal from the Marching Band.
• Sat. July 18 - Camp Student/Parent Meeting 8:00 AM in the Corona Auditorium Lobby for new
members to be fit for shoes & gloves, 9:30 AM in the Auditorium for the All Band Family meeting to
go over Band Camp details.
The Corona del Sol Aztec Marching Band will depart for Pine Summit Camp for their annual Summer
Marching Band Camp on Sunday July 19. Members will be at camp through Saturday, July 25. The
Summer Marching Band Camp is required for all marching band members, so make summer plans
accordingly!
The purpose of the camp is to get the year kicked off to a great start and to get the fundamentals of
marching learned while avoiding the valley heat. Camp also offers the opportunity to build strong
personal relationships within the band, so that the marching season runs much more smoothly. All of
the camp and pre-camp activities are VERY IMPORTANT and thus we need 100% attendance!!!
Parents must pick up their student(s) from Camp on Saturday, July 25 in Prescott. Families are
encouraged to attend the Camp BBQ from 11am-12pm on Saturday; order forms are enclosed. We will
end camp with a celebratory concert at 12:30pm. Transportation is not provided back to Tempe. All
parents are expected to come on Saturday, July 25, OR make arrangements for their student(s) to ride
home with another family.
Students will stay in cabins and dormitories of various sizes at Camp. There is a nice dining hall with staff
provided to prepare all of the meals. Students will participate in marching rehearsals, music rehearsals,
and fun activities throughout the week. Band Camp 2015 should prove to be exciting and memorable
for all!
Please see the other side of this page for information about the fees for band camp and deadlines. à
Band Camp Fees
The normal cost of camp is $425.00, which covers everything outlined here, including bus
transportation to camp and meals. However, if you pay early – you will receive a
discount. There is an extra fee if you pay late. Please realize that no refunds will be issued
by the camp or the school once checks have been sent in, regardless if the student
participates or not.
DEADLINES:
(Submission date is Postmark)
EARLY BIRD Cost (pay in full by May 6): $400.00 (includes $25 discount!)
NORMAL Cost (pay in full between May 7 to May 18): $425.00
LATE Cost (pay after May 19): $475.00 (includes $50 late fee)
Please make checks payable to: Corona del Sol.
Please send a check with “Band Camp 2015” and your student’s name in the memo
of the check. You can mail the check or bring directly into the bookstore during school
hours. If you bring into the bookstore, please ensure that the receipt is given to Mr.
DuPlessis. You can pay as a tax credit, just fill out the enclosed form and send with your
check if you are using the tax credit option.
Corona del Sol HS Band
Attn: Band Camp
1001 E. Knox Rd.
Tempe, AZ 85284
The final meeting for parents and students will be held Saturday, July 18th, at 9:30 am in
the Corona del Sol auditorium (if you need to order new shoes, gloves, or other items,
please arrive at 8 am to be fitted). Please reserve this date and plan to be at this meeting
along with your parent(s). For COLOR GUARD members – there is an additional color
guard fee to pay for uniforms and more – please see this info on “estimated costs.”
Sincerely,
David DuPlessis, Director
Corona del Sol Bands
[email protected]
Scott Werner, Director
Corona del Sol Percussion
[email protected]
P.S. - Visit the Band Booster Website for updates on band events: www.cdsband.org
Estimated COSTS for participation in the Aztec Marching Band
< PLEASE READ THIS THROUGHLY! >
Below is a list of expenses that marching band students can expect
to pay throughout the course of the season. If you need financial assistance or a
payment plan, please contact Mr. DuPlessis ([email protected]) immediately!
SCHOOL FEES
Course Fee: Some courses including Band (JV Band, Intermediate Band, Varsity Band, Wind Ens.) have a
course fee that needs to be paid at book distribution in July that covers the cost of supplies used in the
class. Last year, this fee was $30 for concert bands and percussion classes (to be paid July 2015).
Activity Fee: The activity fee was designed to help offset the Maintenance & Operation expense of
providing extra-curricular student activities in the Tempe Union High School District.
This is why the district charges $50.00 for the activity outlined in policy GCB-E. The TUHSD board voted
upon this fee in April 2003. Please see the activity fee schedule. These fees are $50.00 per activity
(including MARCHING BAND) with a maximum of $150.00 for any one student and no family maximum.
The $50 activity fee is due July 2015.
GOOD NEWS!
As of April 2015, the Tempe Union HS District has eliminated the marching band zero hour fee –
there will be NO additional fee for the marching band course! (last year this fee was $175).
However, other zero hour courses will still carry the $175 fee if it is beyond the student’s six regular
classes (such as Zero Hour Steel Band/World Music and Jazz Bands).
COLOR GUARD MEMBER FEE (due by July 1) - $350. Please keep in mind this fee is separate than the
band camp free. PLEASE MAKE CHECKS PAYABLE TO CORONA DEL SOL BAND BOOSTERS – do not
turn this in to the school bookstore, but rather mail it or turn it in to Mr. DuPlessis at the school address.
---------CAMPS/TRIP costs for ALL Marching Band members
o Band Camp, July 19-25 – see camp letter for costs and deadlines. MAKE THIS CHECK
PAYABLE TO “CORONA DEL SOL” AND TURN INTO THE BOOKSTORE (OR MAIL IN TO THE
SCHOOL). YOU CAN USE THE TAX CREDIT OPTION TO PAY FOR THIS TRIP, AND GET THE MONEY
BACK ON YOUR STATE TAXES! If you do tax credit, be sure to fill out the separate attached form
and include with your check.
o California Trip – Bands of America Regional Championship, October 2014 - $325.00 (DUE
SEPTEMBER 1). PLEASE MAKE THIS CHECK PAYABLE TO “CORONA DEL SOL BAND
BOOSTERS” AND TURN INTO MR. DUPLESSIS. DO NOT PAY THIS FEE TO THE BOOKSTORE.
---------INSTRUMENT/UNIFORM costs for Woodwinds and Brass only
Marching Shoes – approx. $40.00 (to be paid for at the band camp meeting on July 18)
Gloves (approx. 4 pair) – approx. $4.00 ea. (to be paid for at the band camp meeting on July 18)
Other supplies – flip folders, flip pages (to be paid for at the band camp meeting on July 18)
Uniform Dry Cleaning approx. $15.00 (District pays for it once, you pay for it once in October)
INSTRUMENT/UNIFORM costs for Percussion only
Marching Shoes - approx. $40.00 (to be paid for at the band camp meeting on July 18)
Battery Percussion maintenance cost (heads) $50.00
Pit Percussion fall season mallet costs $45.00 (approx)
Uniform Dry Clean approx. $15.00 (District pays for it once, you pay for it once in October)
2015 Aztec Marching Band Camp Packing List
YOU MUST HAVE:
___ Folding Music stand (the camp doesn’t provide stands! Bring your own)
___ Backpack to carry your day supplies and music binder around the camp.
___ Old beach towel to do stretching on in the morning
___ Instrument, Equipment and supplies (mouthpieces, reeds, tape, cleaning etc.)
___ Show Music (large pages) in a binder (with plastic sheet protectors) and Pencils
___ Flip folder for music w/10 pages for small music (stand tunes)
___ Sleeping Bag and twin fitted sheet for the bed in the cabin and Pillow
___ Pajamas
___ Pants—Two (2) pair
___ Athletic Shorts - Two to three (2-3) pair (no spandex shorts for rehearsals – they can be worn under
regular athletic shorts)
___ T-Shirts – six (6) (No Halter tops or sleeveless t-shirts, No bare bellies)
___ Socks and Underwear for six (6) days: six changes of underwear and socks
___ Raincoat or poncho (it does rain occasionally!); Jacket and/or sweatshirts
___ Hat – MUST HAVE should cover entire top of head - visors are not adequate.
___ Tennis/Running shoes only – no skate shoes (shoes should be comfortable and broken in) Note: Shoes
are required at all times at camp so you may want to bring two (2) pairs. NO SANDALS are
permitted at the camp, except for flip flops for the shower
___ Personal items: Deodorant, soap, shampoo, comb, brush, toothbrush & toothpaste, insect repellent,
Kleenex, sanitary supplies, SUNSCREEN (SPORT TYPE/ SWEAT PROOF), protective lip balm, aloe for
sunburn, ace bandages, Icy Hot, and contact lens supplies.
___ Personal Prescriptions & medications (including Tylenol/Ibuprofen, etc.): Note: ALL FORMS of pills or
medication(s) must be listed on band information form. You must keep and administer your
own medicine. All medicines must be in the original labeled bottle.
___ Large bag for dirty clothes (plastic garbage bag is fine)
___ Towels and washcloth
___ Alarm Clock and watch
___ Flashlight with extra batteries
___ Sunglasses/glasses
___ Healthy Snacks for break times (leave sodas, candy, and coolers at home – don’t bring these items!)
___ CASH for lunch meal on the way up to camp (we will stop at the mall for lunch)
___BAND WATER BOTTLE with your name on it (provided for new members, returning members should
have theirs from last season. If not, you can buy a new one for $10)
NICE TO HAVE, BUT OPTIONAL:
___ Camera
___ Notebooks for skit/activities; games, cards, basketball, football, etc.
___ Paper and supplies for friendship mail
___ Costume for dance and spirit days
THINGS YOU SHOULDN’T BRING
The purpose of Band Camp is to build relationships with other members. Toward this end, we highly
recommend that you leave distracting electronic items at home, including, for example, music players, cell
phones, portable game players, hair dryers, and curling irons. If such items become a distraction to you or
others, we reserve the right to confiscate the items and return them to you after camp. Cell phones are not
allowed anywhere outside of cabins.
DIRECTIONS TO PINE SUMMIT CAMP
From I-17, take Highway 69 West to Prescott (approx. 36 miles). Stay in left lane and follow Gurley Street into Prescott.
Turn south (left) off Gurley Street onto Mt. Vernon Street, which becomes Senator Highway south of town. Travel about
seven miles, at which time the blacktop ends. Continue on the gravel road for approximately 100 yards, and watch for the
GURLEY ST.
SHELDON ST.
M
T.
V
E
R
N
O
N
HIGHWAY 69
TO I-17
Pine Summit sign. Turn right at the sign and after traveling about a quarter mile, turn right again into Pine Summit Camp.
N
S
SENATOR HWY.
PINE SUMMIT
CAMP SIGN
Corona del Sol Bands Information Form and Discipline Agreement
Band camp and band trips are wonderful opportunities to develop and grow as performers and as
individuals. In order to maintain a positive and safe environment, the following band rules will be in
effect during all band camps, trips, practices, games, competitions, meetings and events. Band camp
and band trips are school functions and therefore all school rules as well as band rules are in force.
Any infraction of the rules could and probably will result in the following:
1. Phone call to parent
2. Being sent home (at parent expense)
3. Possible (probable) dismissal from the band for the rest of year
4. Consequences from the school administration upon return from the event for all
school rules that are broken, including suspension or expulsion from school.
THE RULES:
• IF EVERYONE DID IT, WOULD IT WORK?
• Perfect attendance is expected and required for all rehearsals, games, festivals,
competitions, and any other public performance on the band calendar at cdsband.org.
• Students/Parents agree to everything laid out in the Band Handbook (at cdsband.org)
• Students will arrive at “call time” ready to perform (i.e. – in uniform at assigned location)
• Corona Band members do not use profanity, or abusive language to others.
• Stealing is not tolerated. This includes money, music, personal items, etc.
• Students are expected to follow the directions of staff instructors at all times – insubordination
or disrespect to adults is not tolerated.
• Smoking is STRICTLY PROHIBITED BY THE SCHOOL AND THE BAND.
• The possession of alcohol, drugs or weapons is STRICTLY PROHIBITED BY THE SCHOOL
AND THE BAND. This will lead to dismissal from the band.
• Breaking of curfew is not allowed and consequences will follow.
• Clothing: revealing clothing is not allowed.
• Rehearsal Uniform for all rehearsals: White t-shirt, athletic shorts, athletic shoes (at
camp, different colored t-shirts are acceptable)
The following are not permitted at band functions:
• Short shorts (that reveal portions of your rear-end or undergarments)
• Spandex shorts or pants (“yoga pants”) - these can be worn under a uniform, but not
as rehearsal shorts.
• Crop tops, tube tops, or any shirt that reveals your mid-section (Girls: Any shirts that
reveal cleavage or undergarments), Muscle shirts and Tank tops or other “sleeveless”
shirts
• “Vans” or “skater” style shoes. Only athletic shoes are permitted in rehearsal.
Please fill out the “Corona Bands Information Form and
Agreement” on cdsband.org. This will also include important
information regarding medication, food allergies, and more.
Deadline: Monday, May 18
“GREEN” Form
CONSENT FOR EMERGENCY CARE _________________________________________________________________________________________________________ Student Name Student ID # Date of Birth Age _ _________ ______ Parent(s)/Guardian(s) Name Home # Cell # Work # Address City Zip Email Emergency Contact – Person who can answer on your behalf for your child in an emergency Home# Cell # Work# If emergency service involving medical action or treatment is required and the parent(s) or guardian(s) cannot be contacted, I hereby consent for the student named to be given medical care by the doctor or hospital selected by the school. _________________________________________________________________________________________________________________ Name of Family Physician Phone Number Date of current physical STATEMENT OF INSURANCE COVERAGE (All students MUST have some type of insurance.) Please choose either Option1 or Option2. OPTION 1 I affirm that I am the parent or Legal Guardian of the student signing this form. I request that this student be exempt from the school accident insurance requirements for students participating in athletics and certain other school activities. I represent that this student is currently covered and will be covered during the present school year by an accident insurance policy which provides at least in the equivalent sums and coverage as the policy offered by the school. This includes coverage in the event of injury in a school supervised game or activity. Company Name_____________________________________ Phone #________________________________ Policy #____________________________________ OPTION 2 I/We desire insurance that will fulfill the school accident insurance requirement. I have purchased school accident insurance (type) __________________/$_________ Effective date: _________ School Official Signature: ________________________ HEALTH HISTORY (To be filled out by parent) HAS YOUR CHILD EVER HAD OR NOW HAS: Please circle YES (Y) or NO (N)
Y Y Y Y Y Y Y N N N N N N N Allergy Arthritis Back Pain Loss Consciousness Eczema(Skin Rash) Epilepsy (Seizures) Chest X‐Ray Y Y Y Y Y Y Y N N N N N N N Kidney Trouble Migraine Headaches Knocked Out Concussion Sore Throats Anemia Tetanus Booster Y Y Y Y Y Y Y N N N N N N N Diabetes
Fainting
Heart Murmur
Hernia
Menstrual Cramps Mononucleosis
Other
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Valley Fever
Heart Trouble
Spine Injury
Ankle Injury
Neck Injury
Elbow Injury
Y
Y
Y
Y
Y
Y
N N N N N N Hepatitis Scoliosis Sinus Trouble
Operations Fractures Hives Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Sprains
Dislocations
Contact Lenses
Tuberculosis
Rheumatic Fever
Asthma
If YES, give year and details: Medication (s) now taking: Medicine(s) student is allergic to: Does student have to stop while running ½ mile? YES NO Consent for Core Temperature via Rectal Thermometer YES NO SPORT: FALL: WINTER: SPRING: THIS FORM MUST BE SIGNED BY STUDENT AND PARENT OR LEGAL GUARDIAN BE IT KNOWN, that, I, the undersigned parent/guardian of the above named student, do hereby give and grant unto any medical doctor, hospital, paramedic or certified school athletic trainer, my consent and authorization to render such aid, treatment or care to said student as, in judgment of said doctor, hospital, paramedic, or certified school athletic trainer, may be required, on an emergency basis, in the event the above‐named student should be injured or stricken ill while participating in an interscholastic activity sponsored or sanctioned by Arizona Interscholastic Association, Inc. of which the above named high school is a member. IT IS HEREBY understood the consent and authorization given are continuing, and are intended throughout the current school year. IT IS FURTHER understood that insurance or parent of student will pay any expenses incurred. Payment of expense is not a school responsibility. “I/we recognize that the foregoing is a public document
and falsification of information on that document to obtain admission to the Tempe Union High School District may constitute violation of the criminals in laws of the State of Arizona. I/we hereby certify
that all the information contained in the Tempe Union High School District Athletic Participation Form is true and correct and recognize that in the event that any information in regard to residence has been falsified, I/we will be liable for nonresident tuition from the date of enrollment in the Tempe Union High School District (TUHSD).”
IT IS FURTHER understood that any falsification on this document may result in student losing a year’s participation and eligibility in interscholastic athletics in the TUHSD. I represent and certify that I and my parent/guardian have read the entirety of this document and fully understand the contents, consequences and implication of signing this document and that I agree to be bound by this document. ____________________________________________ ____________________________________________ ____________________________________ Student (PRINT) Student (SIGNATURE) Date ____________________________________________ ____________________________________________ ____________________________________ Date Parent/Guardian (SIGNATURE) Parent/Guardian (PRINT) MUST BE COMPLETED BY NOTARY PUBLIC OR PARENT MUST SIGN IN FRONT OF A SCHOOL ADMINISTRATOR State of } } Country of } The above named person, who is known to me or has provided proper identification, signed before me his/her name on this document on this ______________ day of ______________________, 20__________ My Commission Expires: ________________________________ Notary Public or Administrator Signature: ________
___________________________________ __
___
__
The Preferred Health Care
Partner of the Arizona
Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 North 18th Street, Phoenix, Arizona 85020-5552
Phone: (602) 385-3810
2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION
(The Parent or Guardian should fill out this form with assistance from the student athlete.)
Exam Date:
In case of emergency, contact:
Name:
Sex:
Name:
Age:
Relationship:
Date of Birth:
Phone (Home):
Grade:
(Work):
School:
(Cell):
Sport(s):
Address:
Name:
Phone:
Relationship:
Personal Physician:
Phone (Home):
Hospital Preference:
(Work):
Explain "Yes" answers on following page.
Circle questions you don’t know the answers to.
(Cell):
Y
1) Has a doctor ever denied or restricted your participation in sports for any reason?
2) Do you have an ongoing medical condition (like diabetes or asthma)?
3) Are you currently taking any prescription or nonprescription (over-the-counter) medicines or supplements?
(Please specify):
4) Do you have allergies to medicines, pollens, foods, or stinging insects?
(Please specify):
5) Does your heart race or skip beats during exercise?
6) Has a doctor ever told you that you have (check all that apply):
High Blood Pressure
A Heart Murmur
High Cholesterol
A Heart Infection
7) Have you ever spent the night in the hospital?
8) Have you ever had surgery?
* 9) Have you ever had an injury (sprain, muscle/ligament tear, tendinitis, etc.) that caused you to miss a practice or
game? (If yes, circle affected area in the box below):
*10) Have you had any broken/fractured bones or dislocated joints?
(If yes, circle affected area in the box below):
* 11) Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical
therapy, a brace, a cast, or crutches? (If yes, circle affected area in the box below):
□ Head
Hand/Fingers
1
Neck
Shoulder
Chest
Knee
Upper Arm
Upper Back
Calf/Shin
Elbow
Low Back
Ankle
Forearm
Hip
Foot/Toes
NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
Thigh
N
The Preferred Health Care
Partner of the Arizona
Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 North 18th Street, Phoenix, Arizona 85020-5552
Phone: (602) 385-3810
Y
12) Have you ever had a stress fracture?
13) Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?
14) Do you regularly use a brace or assistive device?
15) Has a doctor told you that you have asthma or allergies?
16) Do you cough, wheeze, or have difficulty breathing during or after exercise?
17) Is there anyone in your family who has asthma?
18) Have you ever used an inhaler or taken asthma medicine?
19) Were you born without, are you missing, or do you have a nonfunctioning kidney,
eye, testicle or any other organ?
20) Have you had infectious mononucleosis (mono) within the last month?
21) Do you have any rashes, pressure sores, or other skin problems?
22) Have you had a herpes skin infection?
23) Have you ever had an injury to your face, head, skull or brain (including a concussion, confusion, memory loss
or headache from a hit to your head, having your “bell rung” or getting “dinged”)?
24) Have you ever had a seizure?
25) Do you have headaches with exercise?
26) Have you ever had numbness, tingling, or weakness in your arms or legs after being hit, falling, stingers or burners?
27) When exercising in the heat, do you have severe muscle cramps or become ill?
28) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?
29) Have you ever been tested for sickle cell trait?
30) Have you had any problems with your eyes or vision?
31) Do you wear glasses or contact lenses?
32) Do you wear protective eyewear, such as goggles or a face shield?
33) Are you happy with your weight?
34) Are you trying to gain or lose weight?
35) Has anyone recommended you change your weight or eating habits?
36) Do you limit or carefully control what you eat?
37) Do you have any concerns that you would like to discuss with a doctor?
Females Only
Explain “Yes” Answers Here
Y
N
38) Have you ever had a menstrual period?
39) How old were you when you had your first
menstrual period?
40) How many periods have you had in the
last year?
2
NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
N
The Preferred Health Care
Partner of the Arizona
Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 North 18th Street, Phoenix, Arizona 85020-5552
Phone: (602) 385-3810
2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION
(The Physician should fill out this form with assistance from the Parent or Guardian.)
Student Name:
Date of Birth:
Patient History Questions: Please tell me about your child...
Y
N
Y
N
1) Has your child fainted or passed out DURING or AFTER exercise, emotion or startle?
2) Has your child ever had extreme shortness of breath during exercise?
3) Has your child had extreme fatigue associated with exercise (different from other children)?
4) Has your child ever had discomfort, pain or pressure in his/her chest during exercise?
5) Has a doctor ever ordered a test for your child's heart?
6) Has your child ever been diagnosed with an unexplained seizure disorder?
7) Has your child ever been diagnosed with exercise-induced asthma not well controlled with medication?
Family History Questions: Please tell me about any of the following in your family...
8) Are there any family members who had sudden, unexpected, unexplained death before age 50? (including SIDS, car accidents, drowning, or
near drowning)
9) Are there any family members who died suddenly of "heart problems" before age 50?
10) Are there any family members who have unexplained fainting or seizures?
11) Are there any relatives with certain conditions, such as:
Y
N
Enlarged Heart
Marfan Syndrome (Aortic Rupture)
Heart Attack, age 50 or younger
Hypertrophic Cardiomyopathy (HCM)
Pacemaker or Implanted Defibrillator
Dilated Cardiomyopathy (DCM)
Deaf at Birth (Congenital Deafness)
Heart Rhythm problems:
Explain “Yes” Answers Here
Long QT Syndrome (LQTS)
Short QT Syndrome
Brugada Syndrome
Catecholaminergic Polymorphic Ventricular
Tachycardia (CPVT) Arrhythmogenic Right Ventricular
Cardiomyopathy (ARVC)
I hereby state that, to the best of my knowledge, my answers to all of the
above questions are complete and correct. Furthermore, I acknowledge
and understand that my eligibility may be revoked if I have not given
truthful and accurate information in response to the above questions.
Signature of athlete
Signature of parent/guardian
Signature of MD/DO/
N
N
D/N
MD/ P/PA-C/CCSP
3
Date
Date:
NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
FORM 15.7-A
02/14
The Preferred Health Care
Partner of the Arizona
Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 North 18th Street, Phoenix, Arizona 85020-5552
Phone: (602) 385-3810
2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION
Name:
Date of Birth:
Age:
Sex:
Height:
Weight:
% Body fat (optional):
Pulse:
BP:____ /____ (____ /____,____ /____)
Vision:
R20/_____
L20/_____
Pupils:
Equal_____
Unequal____
Normal
Corrected: Y___ N___
Abnormal Findings
Medical
Appearance
Eyes/Ears/ Throat/Nose
Hearing
Lymph Nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary †
Skin
Musculoskeletal
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
NOTES:
* Multi-examiner set-up only.
† Having a third party present is recommended for the genitourinary examination.
Cleared Without Restriction
Not Cleared For:
All Sports
Recommendations:
Certain Sports
Reason:
Name of Physician(Print/Type):
Exam Date:
Address:
Phone:
Signature of Physician:
, MD/DO/ND/NMD/NP/PA-C/CCSP
FORM 15.7-B
03/12 NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
Initials*
Band Camp Family BBQ Order Form
Saturday July 26, when you come to camp to pick up your
student from Band Camp, lunch will be available for purchase
from the Band Boosters for all families for a fee of $8 per person.
Meals will need to be preordered and paid for by May 18.
STUDENTS IN THE MARCHING BAND DO NOT
NEED TO ORDER A BBQ MEAL – IT IS PROVIDED. J
Cost is only $8 per person and includes:
• Hamburger or Veggie Burger or Pulled Pork Sandwich
• Chips
• Cookie
• Pasta Salad
• Ice Cold Drink
The Cookout is 11 AM to 12 PM (before the Concert).
Please complete the order form below and include with your Band Camp forms.
Payment should be made to CORONA DEL SOL BAND BOOSTERS (it should be a
separate check from your band camp check). Staple the check to this form
when returning the form.
Family and student name __________________________
Hamburger meal _____
Pulled Pork Sandwich meal _____
Veggie Burger meal _____
Total meals _____ x $8 each = $______Total
Please make checks payable to CDS Band Boosters and return form with
completed Band Camp forms. Make sure your BBQ check is separate from
your Camp Fees check and is stapled to this form.
Questions? e-mail our BBQ Chairperson:
Kathy Askins
[email protected]
BAND BOOSTERS MEMBERSHIP APPLICATION 2015-2016
FAMILY PRICE of $30.00 includes:
• Full membership in Corona del Sol Band Boosters.
• FREE copy of the Band Booster Directory (a $5.00 value)
• FREE Marching Band professional DVD OR Bluray (a $30.00 value)
• FREE Frys or Bashas reloadable gift card ($5.00) value
THE MEMBERSHIP DIRECTORY IS PRINTED WITH THE INFORMATION PROVIDED BELOW
To be included in the directory, this form and payment are due by August 15, 2015
PLEASE PRINT LEGIBLY!!!
Parents’ name(s): ________________________________________________________________
Mailing address: _________________________________________________________________
City: __________________________ Zip: ______________ Home Ph:(______) _______________
E-mail ___________________________________________Cell Ph: (______) ________________
Student (s)
Name
Concert Band
Instrument
Marching
Instrument
Group
BAND = Brass/Woodwind;
PERC = Percussion;
CG = Color Guard
Class
BAND
PERC
CG
FR
JR
SOPH
SR
BAND
PERC
CG
FR
JR
SOPH
SR
BAND
PERC
CG
FR
JR
SOPH
SR
IF YOU DO NOT WANT YOUR NAME LISTED IN THE DIRECTORY, CHECK THIS BOX.
Checks should be made payable to CdS Band Boosters
Return form with check stapled to it with other
Band Camp forms, or mail separately to:
CdS Band Boosters, Inc.
c/o Dan Pote
4184 W. Harrison St.
Chandler, AZ 85226
“PINK” Form
Tax Credit Donation Form
Please print this form and submit with your tax credit donation. A receipt will
be mailed to the contributor for tax filing purposes.
 Yes! I’d like to help our students.
Distribute the enclosed donation of: $ _____________(up to $400)*
To ___________________________ High School.
Identify area of donation (i.e.; specific activity, club, sport, other or no designation):
Corona del Sol Bands
Full Name:
Address:
City:
State:
Home phone:
Work phone:
Zip:
Mail this completed form along with your contribution check,
made payable to the high school of your choice, to the attention of
the Bookstore Manager at the school you've chosen.
Tempe High School
1730 S. Mill Ave.
Tempe, AZ 85281
McClintock High School
1830 E. Del Rio Drive
Tempe, AZ 85282
Marcos de Niza High School Corona del Sol High School
6000 S. Lakeshore Drive
1001 E. Knox Road
Tempe, AZ 85283
Tempe, AZ 85284
Mountain Pointe High School Desert Vista High School
4201 E. Knox Road
16440 S. 32nd St.
Phoenix, AZ 85044
Phoenix, AZ 85048
Compadre High School
500 W. Guadalupe Road
Tempe, AZ 85283
*Reminder: Tax credit is up to $200 for per individual tax return and up to $400 for
married filing jointly. Contact your tax advisor for more information.
Thank you for supporting Tempe Union High School District.