EmailMe Form - Jacksonville Children's Chorus- PreK Music 2014

Child's Name *

First Last

Gender *

Female

Male

Age *

Date of Birth *

MM / DD / YYYY

Please select which class you wish to participate in: *

Mon, Aug 4 - 10am-10:50am (18mo to 2 1/2 years) 1 spot available

Tues, Aug 5 - 9:30am-10:20am (18mo to 2 1/2 years) 8 spots available

Thurs, Aug 7 - 9:30am-10:20am (2 1/2 years to 4 years) 1 spot available

Ethnicity *

Parents or Guardians *

Child's Home Mailing Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent 1/Guardian 1 Contact information

Name *

First Last

Home Phone *

### - ### - ####

Employer:

Work Phone

### - ### - ####

Cell Phone

### - ### - ####

Email

Parent 2/Guardian contact information

Name(2)

First Last

Home Phone (2)

### - ### - ####

Employer:(2)

Work Phone (2)

### - ### - ####

Cell Phone (2)

### - ### - ####

Email(2)

In consideration of my child's participation in the Jacksonville Children's Chorus Preschool Music Program, I hereby authorize the videotaping, photography, and recording of the above referenced registrant, and/or release of his/her name and achievements for educational, promotional, and other purposes deemed appropriate by officers of the Jacksonville Children's Chorus. I also authorize the use of the videotape/photography and other information regarding my child in printed matter or other media for presentations by the Jacksonville Children's Chorus without my further consent. I hereby agree that such media information shall be the sole property of the Jacksonville Children's Chorus. *

I agree