KCC Year 2020-21

KETTERING CHILDRENS CHOIR

SINGER REGISTRATION & MEDICAL RELEASE
Select at least one

New Audition Auditioning for Step-up Chorus Chorale Concert Cappella
Please complete this form to ensure your 2020-2021 place in the choir.
Singer's Name

First Name Last Name
If New, who referred singer?

First Name Last Name
Birth Date

Month Day Year
School in the Fall
Grade in the Fall
Music Teacher
Gender

Male Female
T-Shirt size (if you are new to KCC or need a new one)

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large
Address

Street Address

Street Address Line 2

City State

Zip Code
Parent/Guardian/Singer and Additional Contact Information
Name

First Name Last Name
Relationship
Ex: Mother or Step Mother
Phone Number

Area Code Phone Number
E-mail
Name

First Name Last Name
Relationship
Ex: Mother, Father or Step Father or Grandmother
Phone Number

Area Code Phone Number
E-mail
example@example.com
Name

First Name Last Name
Relationship
Ex: Singer
Phone Number

Area Code Phone Number
E-mail
example@example.com
Singer lives with
Emergency Information
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Physician

First Name Last Name
Phone Number

Area Code Phone Number
Dentist

First Name Last Name
Phone Number

Area Code Phone Number
Does the singer have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the singer prescribed an inhaler? If yes, please explain any instructions.
Insurance Carrier
Policy/ID#
Medical Release and Authorization

In the unlikely event that my child becomes ill or is injured, and I, or the authorized physician named, cannot be immediately contacted at the time of an emergency, and if in the judgment of the staff of the Kettering Children’s Choir immediate observation or treatment is necessary, I authorize and direct the staff to send my child (properly accompanied) to the hospital or physician most easily accessible. I release the Kettering Children’s Choir, their employees, and agents from any claim of liability in connections therewith.
PHOTOGRAPHIC RELEASE

The undersigned agrees without compensation to permit The Kettering
Children’s Choir, its agents, assignees and employees to use photographic
images or likenesses of the below listed singer(s) for use and benefit of
The Kettering Children’s Choir in its publications and other organizational
development and promotional programs. This release shall continue in
force until specifically revoked.
Commitment Statement

WE UNDERSTAND THAT THE SINGER IS MAKING A FULL-YEAR COMMITMENT AND AGREE TO PARTICIPATE FOR THE ENTIRE SEASON. WE ALSO UNDERSTAND THAT WE ARE MAKING A FINANCIAL COMMITMENT FOR THE COMPLETE TUITION RATE, WHICH IS NON-REFUNDABLE.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Type a question
Signature of Parent or Guardian *

Clear
Signature of Singer

Clear
Should be Empty:

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KETTERING CHILDRENS CHOIR