LWC - Band Information Form

Student Information:

Name:
Birth Date:
Address:
City, State Zip:    
Phone: (home)    (cell)
E-mail Address:
Parents Information:
Father: (phone)   
Mother: (phone)   
Other Information:
T-Shirt Size:   Shoe Size:  
Check ONE: Resident:         Commuter:
If resident, what dorm?
Any medical issues that we need to be aware of?