RSCM Pacific Northwest: Adult Registration Form 2020
Please fill out & click submit. Questions? Technological difficulties? Email rscmpnw@gmail.com.
Email address *
First Name *
Last Name *
What do you like to be called?
Date of Birth *
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DD
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Street Address *
City *
State *
Zip Code *
How long have you lived at the above address? *
If less than 12 months, list previous address: *
Cell phone (phone you will have at the course) *
Home phone
Work phone
Email *
What is the best way to reach you? *
Current Employer *
How long have you been employed there? *
Church or Choir Name *
Church or Choir Address *
Church or Choir City *
Church or Choir State *
Are you the choir director of your church? *
If no, please list choir director's name:
Choir Director's Phone
Choir Director's Email:
Priest's Name (if applicable; if not, please list your second reference & relationship)
Priest's Phone
Priest's Email
Voice Part *
(Adult sopranos should be willing to sing alto. Contact us with questions!)
Prior RSCM course experience: *
If no prior courses attended, please explain your interest in attending RSCM Pacific Northwest!
Select the option below that best describes your musical abilities/interests. (This helps us plan our adult education offerings.) *
Preferred t-shirt size (adult sizes): *
Do you have any medical conditions that we should be aware of should there be a medical emergency (i.e. seizures, fainting, asthma, etc.)? If so, please explain here:
Please list any special dietary needs or allergies below:
(N.B. Most special meal needs can be accommodated. Please email rscmpnw@gmail.com for more information.)
Clear selection
Health Insurance Company *
Name on health insurance policy: *
Policy Number *
Primary Care Physician
Primary Care Physician Phone
Emergency Contact Name *
Relationship to applicant: *
Emergency Contact Phone *
Have you taken the Safe Church/Sexual Ethics Training provided by your diocese? *
Where did you complete your training?
What year did you complete your training?
Have you ever been convicted of a criminal offense? *
If yes, please explain.
Have you ever been found by a civil court to have caused significant harm to a child or young person under the age of 18, or has any civil court made any finding against you that any child or young person under the age of 18 was at risk of significant harm? *
If yes, please explain.
I declare that all the information I have provided is true and complete to the best of my knowledge. I acknowledge that an affirmative response below constitutes my signature. *
By entering my name below, I acknowledge that I am aware that I must provide two reference forms and submit the Behavior Contract and Photo Release PRIOR to the beginning of the course. *
REFERENCES: Please provide the name & contact information of two people (ideally one clergy & one lay) who have known you at least two years and who will provide a personal reference. You will find the link to the reference form on the website's Registration page. Please share this link with your references and request they submit no later than May 15. *
Are you or your church a member of RSCM America? *
How will you be paying the deposit for this registration? *
Are you an RSCM PNW Staff Member for 2020? *
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