Gleeful! Registration

REGISTRATION
Participant 1

Contact Person
Name

First NameLast Name
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Gender
Ethnicity

CaucasianLatinoAfrican AmericanNative AmericanPacific IslanderAsianOther
Highest education level completed

K - 12Trade or vocational schoolAssociate DegreeBachelor's DegreeDoctorate DegreeOther
Musical Background? (choir, instruments, dance, etc.)
Favorite songs, musicians and genres?
Would you be interested in solo vocal or instrumental opportunities?

VocalInstrumental
Your own medical concerns that are relevant to choir participation
(physical, respiratory or other relevant conditions)
Which stage of dementia would you classify your partner:

Mild (early stage)Moderate (middle stage)Advanced (late stage)
How long has your partner been diagnosed with dementia?
Problems you are currently facing with regard to dementia
Other medical concerns your partner may have in regard to choir participation
(physical, respiratory or other relevant condition)
I understand that the myself and my care partner must BOTH be present at rehearsals and performances

AGREE
Media Release

1) I, the undersigned, hereby authorize Gleeful to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions).

2) I authorize the use of any such photographic or electronic reproductions ofme for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Gleeful. I understand that I may be identifiable from such photographic or electronic reproduction.
I understand and agree to the media release.
(Typed signature)
Participant 2

Care Partner with Dementia
Name

First NameLast Name
Email (if different from Participant 1)
example@example.com
Phone Number (if different from Participant 1)

Area CodePhone Number
Address (if different from Participant 1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Gender
Ethnicity

CaucasianLatinoAfrican AmericanNative AmericanPacific IslanderAsianOther
Highest education level completed

K - 12Trade or vocational schoolAssociate DegreeBachelor's DegreeDoctorate DegreeOther
Musical Background? (choir, instruments, dance, etc.)
Favorite songs, musicians and genres?
Would you be interested in solo vocal or instrumental opportunities?

VocalInstrumental
Media Release

1) I, the undersigned, hereby authorize Gleeful to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions).

2) I authorize the use of any such photographic or electronic reproductions of

me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Gleeful. I understand that I may be identifiable from such photographic or electronic reproduction.
I understand and agree to the media release.
Typed signature
Should be Empty:

Participant 1

Participant 2