EmailMe Form - FREE Virtual Preschool Class

Type of Registration

Individual

Daycare Center

Preschool

Child's Name *

First Last

Preschool/Daycare Name *

Preschool/Daycare Contact *

First Last

Gender *

Female

Male

Ages *

Age *

Date of Birth *

MM / DD / YYYY

Ethnicity *

Parents or Guardians *

Child's Home Mailing Address: *

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

Mailing Address: *

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

Contact Information

Name *

First Last

Cell Phone *

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

Email *

How did you hear about our Preschool Music Classes? *

What is your combined household income? (Required for funding purposes.) *

$78,400 or less

$78,401 or more

MEDIA RELEASE
In consideration of my child’s participation in these Jacksonville Children’s Chorus classes, I hereby authorize the videotaping, photography, and recording of my child, named in this registration form, 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

I disagree