Memorial HS
Debate
Handbook
2015-2016
Memorial HS Debate
“Tradition of Success!”
Welcome to the Memorial Debate Team! We are very excited that you are a part of one of the most successful
teams in the history of Memorial HS.
Each year we win awards on the local, state and national level. In the last few years we have had students at
UIL State, TFA State, NFL Nationals, and the TOC. Students every year enhance their education by being in
debate. DEBATE IS THE #1 EXTRACURRICULAR ACTIVITY FAVORED BY IVY LEAGUE
SCHOOLS. We have students who are accepted and attend schools such as Northwestern University, Stanford,
Emory, Harvard, Rice, University of Texas (Plan 2) to name just a few.
You have a coach who has National honors and recognitions. Cecil Trent has been coaching for 33 years and
has earned many awards for the National Forensic League, Texas Forensic Association, and the University
Interscholastic League.
Debate in Memorial is “Academic Football.” We have the same expectations of commitment and we KNOW
that you will gain skills that will be useful after high school and throughout life.
Please take a few minutes to review these handbooks with the family. Debate is a “family” activity and it is
important that parents and students know the requirements, expectations, and the obligations necessary. We
will be scheduling a parent night in the very near future.
If you have questions, please free to contact me.
I look forward to working with you and your family.
Sincerely,
Cecil Trent
Director of Forensics
Memorial High School
Contact Information
Debate Coach Information
Cecil Trent, Director of Forensics
Office Phone: 713-251-2500 ext. 2657
Cell: 281-468-0288
Conference: 7th and 8th (By appointment only, please)
Email: cecil.trent@springbranchisd.com
Why should I debate?
Debate in SBISD has a history of success.
.
Why Debate?
Simply put: debate can become your most important classroom. The skills that are learned by competitive debaters are
fundamental to success, both in the academic and professional worlds. The skills that are developed are numerous.
Research – Debaters become very familiar with how to do research at a library and on the internet quickly and
effectively.
Problem Solving & Critical Thinking – If you want to survive in the “real world,” these skills are vital. Hone your
talents against the best students from around the nation who will eventually lead their fields.
Communication Skills – Businesses say the #1 skill they look for when hiring is the ability to communicate with others.
Debaters develop outstanding public speaking skills and are able to answer questions quickly and effectively.
Writing – Debaters spend vast amount of time writing and creating their arguments. This becomes an invaluable skill in
college.
Awareness of the world around you –Debaters have to become very knowledgeable about current events and what it
means to be a global citizen in order to be successful.
College Admissions – Colleges favor debaters
According to Minh Luong, Assistant Professor at Yale University:
“A Wall Street Journal report (April 16, 1999) did specifically highlight a “consistent trend” that dedicated
participation in debate has significantly increased the success rate of college applicants at all schools which tracks
such data. State and national award winners have a 22% to 30% higher acceptance rate at top tier colleges and
being captain of the debate team “improved an applicant's chances by more than 60% compared with the rest of
the pool,” according to the report. This is significantly better than other extracurricular activities that tend to
recruit from the same pool of students as forensic teams such as school newspaper reporter (+3%), sports team
captain (+5%), class president (+5%), and band (+3%). Even without winning major awards, participation in
speech and debate develops valuable skills that colleges are seeking out and that is reflected in the above average
acceptance rate for forensic students (+4%). Colleges and universities today are looking for critical thinkers and
articulate communicators who will become active citizens and leaders of tomorrow.”
Recent graduates of Memorial who were debaters are studying at Yale Law, Harvard undergraduate, Yale, Johns
Hopkins, Duke, Rice, Stanford, Emory, Dartmouth, Georgetown, MIT, and University of Texas- Plan II to name
just a few.”
Why spend time doing this?
It is FUN! No other activity do you get to travel and have the award possibilities that Debate offers. We’ve traveled
to tournaments in Las Vegas, Chicago, Atlanta, Boston, Austin, Dallas, and Berkeley to name just a few. You will
make life long friends from other schools around the nation and abroad.
You get to be around smart people. Most of our students are involved in AP, Pre-AP classes or Gifted and Talented.
Skills that College Favor: The skills you learn will place you ahead of others in the college admission game.
How much after school time does debate take?
Like athletics or music, practice time is expected. This is academic football and you must practice to have success.
Depending on the events in which you specialize, you will be expected to be at 1-2 practices a week. You will also be
expected to attend 1 debate tournament per 9 weeks as a beginner (novice) and 2 per 9 weeks as varsity.
I am involved in other after school events that have practice – can I participate in both?
YES – SBISD has a philosophy of creating well-rounded students. We have a great working relationship with the athletic
coaches and fine art directors. The debate coaches and the other coaches will work together to help. You will be required
to attend practices for both, but this will be worked out for your maximum participation.
Can I be in debate and not be in the class?
NO –debate class is the time to learn the theory and arguments. You must be in the class to succeed.
Can I be in the class and not go to tournaments?
No – you are a part of the team when you join the class. It is like being in athletics and not going to the game. The
classroom provides basic training and the tournament is putting that training into action.
What are the debate events?
CX (cross-examination debate, also called policy) This event has 2 people who are on a team and you will be offer
solutions to contemporary world problems.
LD (Lincoln Douglas Debate) This is a 1-person event. You will be talking about the value or truth of a statement. This
event exposes you to the world of philosophy.
Extemp (Extemporaneous Speaking) This is an individual event that has you speak on a current event topic.
Student Congress –This is like the United States Congress. You will write and debate bills and resolutions that are
national in scope using the same procedures as congress.
Public Forum Debate – This is a relatively new event that has a team of 2 people and they debate the pros and cons of a
topic that is a current issue in the news.
How does a tournament work?
A tournament is the culmination of your hours in the classroom, practice, and research. TOURNAMENTS ARE FUN!
You get to show off your hard work against other people from other schools, you get to learn from good judges/critics,
and you make life long friends. At each tournament there will be between 30 and 50 schools with 500-1200 competitors.
Sometimes there will between 30-120 in each event. You will usually only compete against people of your own level – so
first year students will compete against other first year students. Tournaments usually start at 4:00 pm on Friday. This
usually includes 3 preliminary rounds of debate on that evening. On Saturday, the individual events usually start early
with the last preliminary round of debate being later that morning. After the preliminary rounds are over the top 8-16
teams will advance to the elimination rounds. The hours may seem long and they are but the benefits and fun of the
experience are well worth it.
Will debate be worth my time if I don’t win?
Yes – the skills you will learn in debate are life long. The ability to speak, think and write will place you above others in
the very competitive world of college and career.
Who pays for the tournament fees and what is this thing called the Grapevine Classic?
The school has a budget that pays for some limited supplies. We have to fundraise the rest. The major fundraiser for
the year is the “Rex Fleming Memorial Speech and Debate Tournament.” This is a Texas Forensic Association
qualifying tournament. About 30-40 schools from attend this competition. We will be responsible for everything
from invitations, to providing judges, hospitality, clean up and the actual running of the tournament. Our parent
boosters will be responsible for providing food for the judges and adult guests and well as providing the concession
stand. Everyone enrolled in debate is REQUIRED to work the entire tournament and may NOT leave without
express permission of Mr. Trent
What in the world are U.I.L., N.F.L., T.F.A., and T.O.C.?
These are the initials of the organizations that we are affiliated.
U.I.L. is the University Interscholastic League. This is the governing body of all extra curricular and co-curricular
activities in the state. U.I.L. started as the Texas Debate League in 1911 and expanded into the U.I.L. that we know today
in 1913. Our U.I.L. competition is in the spring and is against the same schools that we compete with in athletics. The
tournaments culminate in the State Tournaments in Austin. Students who participate in the state tournament are eligible
for scholarships to in-state colleges and universities.
N.F.L. is the National Forensic League. They are in the midst of changing their name to the National Speech and Debate
Association. The National Forensic League promotes ethical student leadership by encouraging high school students to
excel in speech, drama and debate. The organization honors students as they perform for service organizations and in
competitive speech tournaments. Formed in 1925, the National Forensic League is a not-for-profit, non-partisan
educational organization with over one million members. Currently, more than 91,000 high school students and more than
3,000 high school teachers are active members. As part of its history, the National Forensic League is proud to claim
among its members such luminaries as: political leaders President Lyndon Johnson, Vice-President Hubert Humphrey,
and Senators Karl Mundt and David Boren; international media visionary Ted Turner; actors James Dean, Shelley Long,
Don Amice, and Oprah Winfrey; television reporters Jane Pauley and Tom Brokaw; and Supreme Court Justice Stephen
Breyer. The National Speech Tournament has been held continuously since 1931 (except for the World War II years) and
has appeared on the approved list of the National Association of Secondary School Principals National Advisory List of
Contests and Activities since origination of the list. Contests are held in policy debate, value debate, legislative debate,
United States Extemporaneous Speaking, Foreign Extemporaneous Speaking, Original Oratory, Dramatic Interpretation,
Humorous Interpretation, Duo Interpretation, Commentary, Impromptu Speaking, Prose Reading, Poetry Reading, and
Expository Speaking.
T.F.A. is the Texas Forensic Association. T.F.A. was founded in the 1970’s and is the primary sponsor of tournaments in
Texas. The tournament calendar starts in August and ends with the State Tournament in March. To qualify for the state
tournament a student must accumulate at least 12 points in each event through participation in elimination rounds at
several tournaments at the varsity level.
T.O.C. is the Tournament of Champions. Many debaters consider this the most challenging national championship for
debate. The championship tournament is held each year at the University of Kentucky the first weekend in May. Only a
few tournaments around the country are designated as T.O.C. qualifiers. A student must qualify twice to be able to
participate or pre-qualify by being an underclassperson in the elimination rounds at the Tournament of Champions the
preceding year.
Memorial Debate Team Rules
1) SBISD policies apply at all times. The coaches and then appropriate school district officials as warranted will handle
violation of any policies.
2) No drugs, alcohol, or tobacco use allowed .
3) Refrain from profanity and vulgarities at all times.
4) Team members are expected to act professionally at all times.
5) No racist, gendered/sexist, heterosexist or religious persecution of any type will be tolerated. Respect the Rights, Property,
and Body of others.
6) No matches or lighters allowed.
7) No Swimming on trips.
8) Promptness is key. Arrive 15 minutes before scheduled time if we are leaving from the school and 2 hours if from the
airport. It is your responsibility to be on time – do NOT rely on the wake up call from the hotel. STUDENTS WILL BE
LEFT BEHIND IF THEIR TARDINESS JEOPARDIZES OTHER MEMBERS OF THE TEAM.
9) Safety procedures (ex. Seat belts) should be followed on all modes of transportation.
10) Adhere to the driver’s expectations at all times.
11) Debaters are responsible for drop fees, transportation, hotel room, and any other expenses incurred due to illness, conflict, or
poor grades.
12) No one will be permitted to leave the tournament site during the debate tournament. You will travel to and from the
tournament with the team when transportation provided. Otherwise, parents will drop you at the tournament and you will be
allowed to leave after all Memorial Debaters are out of the tournament. Any exceptions must be submitted to Mr. Trent
in WRITING by Wednesday prior to the tournament.
13) Follow Dress Code Guidelines. Tournament dress is expected through the awards ceremony or if you are still in elimination
rounds – until you are finished.
14) Watch ALL elimination rounds (especially our team) if not competing. You MAY NOT play cards or other games during
elimination rounds.
15) Sit with the team during awards assembly. Remember to act professionally – this isn’t a pep rally.
16) Follow all tournament host rules.
17) Overnight Trips:
a. Take care of your luggage by placing nametags on all luggage (including tubs). NEVER OVERPACK.
b. Permission form must be signed with all medical information.
c. Sleep only in the room assigned.
d. No phone use out of room unless you put credit card down for deposit.
e. Respect the property of the hotel.
f. Curfew is ABSOLUTE. This includes lights out on evenings of competition.
g. Males and females in same-sex room. If you are working or visiting people from the opposite sex from our team the
door must be blocked open.
h. No visitors from other schools
i. You may not go to rooms of other schools.
18) Permission form must be signed before student can participate in a tournament or activity with the Memorial Debate Team.
19) Students are expected to participate in all fundraising activities.
20) No trading evidence is permitted without the permission of the coach. – NO EXCEPTION
Memorial Debate Class Expectations
All students in debate classes at Memorial High School are expected to be active members of the Memorial Debate
Team. As a result, expectations differ somewhat from the typical class offering. Student assignments will benefit
not only the individual, but also the entire team; therefore, deadlines must be strictly followed. Practices after
school are an extension of the class and are required. Tournament attendance is mandatory. Failure to complete
assignments on time, attend practices regularly, or compete in mandatory tournaments will result in a lower class
grade and possible removal from the class and team.
DEBATE IS NOT STUDY HALL
IF THAT IS YOUR EXPECTATION THEN TAKE STUDY
HALL
1.
Extemporaneous Speaking: All students will compete in Extemp. There will be articles to collect, print, cut, read,
highlight, and file. Students will also be responsible for assigned topic research and possible lectures. Weekly practice
speeches are required. Students should compile a spiral notebook with Extemp speech outlines. Periodic quizzes over
current events will be given.
Debate: All students will compete in either CX, LD or PF debate. Research assignments must be completed on time.
Incomplete research or research of poor quality will be returned and must be redone to receive credit. Students will be
responsible for topic lectures and outside reading. New debate cases and arguments will be required throughout the year.
Outside library time is required.
Student Congress: Some students will choose to “major” in Student Congress. There will be required bill writing,
research, speech writing, and parliamentary procedure. Students will be responsible for creating new legislation,
preparing speeches, and research. Some parliamentary procedure quizzes will occur.
Practices: Regular practices will be held. (Schedule TBA) Additional practices will be scheduled as necessary before
major tournaments (primarily varsity debaters). Any conflict with practice must be cleared in advance. Appointments
SHOULD NOT be scheduled for practice time. Failure to follow this policy will result in forfeiture of tournament slot
and possible dismissal from team.
Tournament Participation:
All members of the Memorial Debate Team are expected to participate in any
tournaments that we host. In addition, members are expected to compete in most local tournaments. Novices (1st year)
must compete in at least 4 tournaments during the year. Varsity (2nd-4th year) must compete in at least 8 tournaments
during the year. All members who qualify for TFA State or NFL Nationals are required to attend and participate in
those tournaments. *Failure to compete at TFA State/ UIL District/as assigned will jeopardize participation at NFL/
TOC.
Financial Responsibilities:
All students are expected to pay their financial obligations prior to each tournament
participation. We ask each debater to pay a fee of $250 for novices, and $350 for varsity. You may make a check
out to MHS Debate. Out of town trips will be paid by the student, including costs of chaperones/sponsors costs when
necessary. Students are responsible for fees incurred in participating in a tournament; anyone failing to compete in a
scheduled tournament for any reason will still be obligated for all expenses including drop fees, travel expenses, and any
other costs incurred by the team. Failure to pay fees or turn in money from fund raisers by deadlines will lead to
forfeiture of tournament slots, dismissal from the team and school records being held. Students pay all their out of state
costs.
Lettering in Debate: Students must accumulate 150 points during their career to qualify for a letter.
2.
3.
4.
5.
6.
7.
Memorial Debate Dress Tournament Dress Code
Since debate is a subjective event and a round can be won or lost on an impression, the following dress code will be followed by
everyone on the team.
Ladies:
1) Professional attire is required. Dresses or Suits are required every round. No pants other than formal PANT
SUITS PREVIOUSLY APPROVED BY A COACH will be accepted. LDers always wear dresses or suits. NO
SLEEVELESS ANYTHING.
2) Dress shoes: Avoid very high heels or “trend” shoes. Nice pumps are best. Make sure that they fit properly and
are appropriate to the suit. Practice walking in your shoes.
3) Wear Hose: Please wear hose; bare legs are not professional.
4) Wear makeup: a small amount helps you look alive and well, but too much can leave the wrong impression. Don’t
wear garish colors or lots of glitter. Makeup suitable for a professional environment is requested.
5) Hair out of face: Hair needs to be worn out of your face and eyes.
6) No gaudy jewelry: Accentuate not detract. DON’T wear bracelets.
7) NO HATS.
Gentlemen:
1)
Professional attire is required.
Suits, dress pants, sports coat, long sleeved dress shirt and tie.
a.
Dark colors – black, gray, charcoal, navy blue are best.
b.
Tie should be professional and tasteful in nature – no cartoons, etc.
c.
d.
e.
f.
g.
2)
3)
4)
Light colored long sleeved shirts are best (white preferable)
DARK SOCKS
No horse patterns or strange patterns on shirts. Solids are best.
Natural fabrics are best. They are cooler and provide a better look.
Shirts should be starched.
Dark Dress shoes: No tennis shoes, deck shoes, or sandals.
Hair needs to be professional looking and out of your face.
NO HATS.
**Stay in dress clothes until the awards and only change with direct permission of the MHS coach.
The goal is to look professional as an individual and team at all times.
COMPETITION BEGINS WHEN YOU EXIT YOUR ARRIVAL VEHICLE.
Novice Debate – Syllabus and Expectations
Debate I at Memorial High School is an elective, i.e. it is not a required class. You can graduate without it.
You are in here because you CHOSE to be here. Thus the course will be taught with the assumption that it is to
your unique advantage to take. In the same vein, you are now a member of the Memorial Debate Team, and
there are expectations of that role as well.
Debate I will develop the student’s research skills, organization of information, and effective use of materials as
applied in various forms of debate and other competitive speaking. The student will become proficient in the
elementary and intermediate processes of logic, reasoning, and critical thinking.
Grades will be calculated based on tournament participation (30%), practice attendance (20%), and daily
assignments (50%).
The course will be teaching the following concepts:
1)
Extemporaneous Speaking/Public Forum Debate
2)
Student Congress
3)
Cross Examination Debate
4)
Lincoln Douglas Debate
Requirements for the Class:
1) This is a “No Hate” zone. Any conduct or activity reasonably considered racist, gendered/sexist,
heterosexist, or religious persecution of any kind will NOT be tolerated and may result in referral to the
office and possible dismissal from the debate class.
2) Dishonesty, cheating, lying will NOT be tolerated.
3) Students must attend and participate in no less than 1 tournament per 9 weeks.
4) Student must participate in designated practices.
5) DO NOT MAKE APPOINTMENTS DURING CLASS TIME OR PRACTICE DAYS! PLAN
AHEAD!
6) Each Debate I student will work 10 hours of the REX FLEMING MEMORIAL TOURNAMENT,
SEPTEMBER 18-19,2015
7) Students will provide judges for the Memorial Tournament.
8) Students will participate in all fund raising activities for the team
9) TARDY POLICY – will be strictly enforced.
10) You will not talk while others have permission to talk. YOU will not curse in class or in the presence of
Mr. Trent.
11) You will complete assignments on time
12) You will follow the rules and expectations (including the dress code) of the Memorial Debate Team
13) You will bring materials to class daily
14) You will respect and protect the rights, property, and body of others.
Materials Needed:
For Daily Class (have here ASAP and EVERY day you are a debater at MHS)
For Daily Class (have here by tomorrow & every day you’re a debater at MHS)
a. Flash drive (minimum 2 GB)
b. Several pens (multiple colors) VERY FINE point. G2’s
c. Yellow highlighters (only – no other colors)
d. 1 box of Kleenex brand tissue (or equivalent quality)
e. 1 digital timer with count up/count down and number pad
f. A laptop is strongly suggested (NOT an IPAD)
g. Binder with several dividers with pockets for handouts.
Varsity Debate Syllabus and Expectations
Varsity Debate is an elective, i.e. it is not a required class. You can graduate without it. You are in here because you CHOSE to be
here. Thus the course will be taught with the assumption that it could be to your advantage to take. In the same idea, you are a
member of the Memorial debate team and there are expectations of that role as well.
Debate I introduced research skills, organization of information, and effective use of materials as applied in various forms of debate
and communications. The student became proficient in the elementary and intermediate processes of logic, reasoning, and critical
thinking to become a successful member of society. Varsity debate will build on these skills and offer more advanced argumentation
techniques, philosophies, and strategies.
The course will be teaching the following concepts:
Extemporaneous Speaking/Public Forum Debate
Student Congress
Lincoln Douglas Debate
Policy (CX) Debate
Grading:
30%
30%
40%
Tournament Participation
Practice Attendance
Daily Assignments/Outside Activities
Requirements for the Class:
1) This is a “No Hate” zone. Any conduct or activity reasonably considered racist, gendered/sexist, heterosexist, or religious
persecution of any kind will NOT be tolerated and may result in referral to the office.
2) Dishonesty, cheating, lying will NOT be tolerated.
3) Students must attend and participate in no less than 2 tournaments per 9 weeks.
4) Student must participate in designated practices.
5) DO NOT MAKE APPOINTMENTS DURING CLASS TIME OR PRACTICE DAYS! PLAN AHEAD!
6) Each Student will work the ENTIRE MEMORIAL TOURNAMENT< SEPTEMBER 18-19, 2015 (Exceptions via Mr.
Trent)
7) Students will provide judges for the Memorial Tournament.
8) Students will participate in all fund raising activities for the team
9) TARDY POLICY – will be strictly enforced.
10) You will not talk while others have permission to talk. YOU will NOT curse.
11) You will complete assignments on time
12) You will follow the rules and expectations (including the dress code) of the Memorial Debate Team
13) You will bring materials to class daily
14) You will respect and protect the rights, property, and body of others.
Materials Needed:
For Daily Class (have here by tomorrow & every day you’re a debater at MHS)
h. Flash drive (minimum 2 GB)
i. Several pens (multiple colors) VERY FINE point. G2 are common in debate.
j. Yellow highlighters (only – no other colors)
k. 1 box of Kleenex brand tissue (or equivalent quality)
l. 1 digital timer with count up/count down and number pad
m. A laptop is mandatory (NOT an IPAD)
Acknowledgement of Rules and Expectations for Memorial Debate
We the parent and ___________________________________ (Student name printed) have read and
understand the rules, expectations, grading policy, and current event assignment of Memorial Debate
team/class. We understand and accept the requirements and realize that not fulfilling the expectations or
assignments will result in discipline and a lower grade in the class. We understand that we must
participate in tournaments, fund-raisers, special programs, and the Memorial Tournament as described
in the handbook and agreed upon by the coaching staff. We understand that not fulfilling these
obligations will lead to disciplinary and financial consequences.
I agree that my child will follow and respect district, school, and squad rules. If my child breaks said
rules and if deemed necessary by the coach (es), I will become responsible for all expenses with regard to
sending my child home immediately.
_______________________________________
Student Signature
__________________
Date
_______________________________________
Parent/Guardian Signature
__________________
Date
Parent email: __________________________________________ (required)
Student email: __________________________________________ (required)
Memorial Debate
Memorial High School
Medical Authorization
Travel Requirements
(PLEASE BE AWARE THESE TRAVEL RULES ARE SUBJECT TO CHANGE VIA NEW BOARD
POLICIES)
As per Board Policy FMG (Local), students who participate in school-sponsored trips shall be required to ride in transportation
provided by the school to and from the event. Exceptions may be made if the student’s parent/guardian presents a written request to
the principal before the scheduled trip requesting that the student be allowed to ride with the parent, with another person designated by
the parent, or that the student be allowed to drive him or herself to the event. The District and its employees will not be liable for any
injuries that occur to students riding in vehicles that the District does not provide. I, and on behalf of my personal representative,
successors, and assigns, hereby agree to release, indemnify, and hold harmless the District, its trustees, employees, and agents from all
claims made against it or them that result from my request to use alternate transportation.
I hereby give permission for my child _________________________________________
(PRINT Child’s Full Name)
to participate in and attend activities with the Memorial Debate Squad during the school year 2015-16. This includes all activities
such as tournaments, fundraisers, etc. I understand when there is a school-sponsored activity my child will be accompanied by and
under the supervision of school personnel. I also understand because of the nature of the activity that my child will not be with the
coach at all times, but that all reasonable precautions will be taken to ensure the safety of my child. I agree that the school and/or
school personnel are not to be held liable for damages caused by my child or any accident or injury sustained by said child. I
understand that all medical information must be disclosed including conditions and medicine that my child is taking. If full disclosure
does not occur, I understand that my child will not be allowed to participate in any other activities until the matter is resolved. I also
understand that medical insurance is mandatory to cover my child in case of an accident.
I give my permission for the above named student to travel according to the following checked alternate transportation methods
(initial ALL that apply):
___ School-provided Transportation (MUST be utilized if leaving during school hours)
___ Ride with Person Designated by Parent
___ Self Transportation
My child has permission to participate in Memorial Debate activities during the 2015-2016 school year. I fully realize that
injury or illness to my child may result from or during participation in these activities. In case of injury or illness, I give
permission for my child to be given medical treatment or dental care as deemed appropriate and to be administered by any
physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States. I further give permission for
the information provided on this form to be shared with appropriate medical personnel. I further give permission for and
grant authority to adult representatives of Memorial Debate to sign on my behalf the Notice of Privacy Practice that patients
are required to receive in accordance with federal law. I understand and acknowledge that I will be responsible for any
medical bills incurred by my child while participating in these activities. I understand that every available effort will be made
to contact me before any treatment is administered.
___________________________________
Parent/Guardian Signature
___________________
Student’s Date of Birth
___________________________________
Telephone/cell phone
____________________________________________________________________________
Allergies (Medications or other)
___________________________________________________________________________________________________
Conditions for which child is currently receiving treatment (Including any current medications)
___________________________________
Emergency Contact Name/Number
___________________________________
____________________________________
Insurance Company**
Policy and/or Group Number**
**MUST INCLUDE INSURANCE INFORMATION