
| First Name: | Last Name: | |||
| I accept to teach week(s): 1 2 3 4 5 6 7 8 9 | ||||
| Dates Teaching: | Year: | |||
| I will be teaching: band orchestra choir guitar piano art chess | ||||
| SS#: | ||||
| Medical Ins Co: | Policy #: Hospital: | |||
| Doctor: | Phone: | |||
| In case of emergency contact: | Phone: | |||
| I authorize emergency medical treatment and/or hostpitalization if necessary: Yes No | ||||
| Family members that will be with you* | ||||