Youth Music Production Program
Please complete the registration below
Participant Information
Last Name
*
First Name
*
Middle Name
Gender
*
Male
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Date of Birth
-
Month
-
Day
Year
Date
This participant is an adult
Contact Information
Address
*
City
*
State
*
Zip
*
Phone number
*
-
Area Code
Phone Number
Emergency Contact Name(if parent or guardian is not avaliable)
*
Emergency Number
*
-
Area Code
Phone Number
Parent/Guardian Information
List first and second choice, not all requests are quaranteed.
First Name
*
Last Name
*
Phone number
*
-
Area Code
Phone Number
Email
*
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Year
Occupation
Employer
Relationship
Mother
Father
Grandparent
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Other
Photography/Videography
I give permission for my child to be photographed and videotaped during program activities.
YES
NO
Signature
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Electronic signature, please initial
*
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