EmailMe Form - November First Steps In Music

Child's Name *

First Last

Gender *

Female

Male

Age *

Date of Birth *

MM / DD / YYYY

Ethnicity *

How did you hear about our "Preschool Music Classes"? *

Participant Information

Child's Home Mailing Address: *

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

Parent/Guardian Contact information

Name *

First Last

Cell Phone *

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

Email (This should be your most often checked email address) *

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

$55,920 or less

$55,921 or greater

Please note: class will be held on November 1, 8, 15 & 22 - Tuesdays 10-10:30am. *

I have confirmed the above class days and time.

MEDIA RELEASE
In consideration of my child's participation in the Jacksonville Children's Chorus First Steps in 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

I disagree