Howard Community College

The Music Institute SEP Consent Form 2019 * = Required Information Online Consent Form also available at: www. howardcc.edu/discover/arts-culture/tmi/tmi-summer-enrichment-reg-form.html Student's Name* _____________________________________________________________________ Parent/Guardian Name * _____________________________________________________________ Date of Birth * ________________________________ Age* _____________ Student's Home Address: * Street _______________________________________________________________________________ City* _______________________________State* _______________ Zip* _______________________ Preferred phone contact number * ______________________________________________________ Email* ______________________________________________________________________________ EMERGENCY CONTACT INFORMATION—Person to Contact in the event of an emergency Parent/Guardian Name* ______________________________________________________________ Emergency Contact Daytime Phone* ____________________________________________________ Name of Alternate Emergency Contact* __________________________________________________ Alternate Emergency Contact Daytime Phone* ____________________________________________ Relationship* ______________________________________ HEALTH INFORMATION FOR THE STUDENT Name of Physician or HMO* ________________________________________________________ Physician's Phone Number*_________________________________________________________ Please list student's allergies* _______________________________________________________ Please list academic, emotional/behavioral, or medical conditions of which staff should be aware* ______________________________________________________________________________________ SCHOOL INFORMATION Is your student currently enrolled in a public or private school in the U.S.?* Yes No If Yes, school attended (2017-18)* ________________________________________ Grade* ___________ School Address* ______________________________________________________ City* _______________________________________ State*_____________________ Zip*_____________ If student is not enrolled in a public or private school in the U.S., a full immunization record is re- quired before registration is finalized. Please submit form DHMH 896 to the Music Institute Office. Is your student exempt from any immunization on medical or religious reasons?* Yes No If student is exempt from any immunization for medical or religious grounds, please submit form DHMH 896 to the Music Institute Office.

• Cover