Middle School Summer Singers Registration
Email address *
Singer first name *
Your answer
Singer last name *
Your answer
Voice part (ask music teacher if unsure) *
T-shirt size *
Grade Completed (2018-2019) *
Your answer
School name *
Your answer
School district *
Your answer
Music/choir teacher's name
Your answer
Parent/guardian name *
Your answer
Parent/guardian phone number *
Your answer
Parent/guardian email *
Your answer
Secondary emergency phone number *
Your answer
Street address *
Your answer
City, State, and Zip *
Your answer
Media Permission and Release
I hereby grant to the Columbus and Central Ohio Children’s Chorus Foundation, its legal representatives, successors, and assigns, and those acting with its authority and permission (jointly and severally, “Columbus Children’s Choir”) the right and permission to copyright, use pictorial depictions of and/or voice recordings of such child or adult, alone or in conjunction with others, made through any media or process, whether now known or unknown, without restriction as to changes, alternations, or reproductions for distribution, sale, broadcast, exhibition, publication, transmission or any other purpose whatsoever, whether commercial or educational. I hereby waive any right to inspect or approve such depictions or recordings, the copy or printed or electronic matter that may be used in connection with them, or the use to which they may be applied. I hereby release and discharge the Columbus Children’s Choir from any liability by virtue of, without limitation, any blurring, distortion, alteration, optical illusion, or use in composite form that may occur or be produced in the taking, processing, distribution, broadcast, exhibition or publication or transmission of the depiction or recording. I certify that I am the parent or guardian of such child or adult, and that I have the authority to make the above grant, waiver, and release on behalf of such child or adult in accordance with the provisions above, and I will indemnify and hold harmless the Columbus Children’s Choir from any claim to the contrary or in any way connected to any matter herein released. I have read and understand the contents of the foregoing Release. *
Media Consent *
Required
Medical Authorization and Release
In the event reasonable attempts to contact me at home have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment deemed necessary by a licensed physician or dentist, and (2) the transfer of the singer any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before the surgery. I grant permission for the Columbus Children’s Choir staff or official chaperones to act as my surrogate in obtaining medical treatment by a licensed physician or dentist, including but not limited to waiver of my HIPAA rights. I agree to assume the financial responsibility for the above. I authorize the release of any information in this form to any health care provider, and in consideration of this undertaking and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, agree to release and indemnify and hold harmless the Columbus and Central Ohio Children’s Chorus Foundation, also known as the Columbus Children’s Choir, and all persons affiliated or associated with it, jointly and severally, from any and all claims, known or unknown, past, present and future, including but not limited to, those arising out of or in any way connected to the release of the information or any treatment rendered to my child. It is my intent that this Emergency Medical Authorization be applicable in any state or district of the United States and in any country outside of the United States. I understand, because this authorization may be used outside the State of Ohio and in other countries outside the United States, that it is dependent upon the law of the individual state or country where any medical treatment may be sought as to whether or not this form will be acceptable evidence of medical authorization. *
Medical Consent *
Required
Allergies to medications, food, or other
Your answer
Injuries, impairments, limitations
Your answer
Insurance provider
Your answer
Group/Policy #
Your answer
Member ID
Your answer
STOP
You must click the blue submit button before you check out with PayPal below. You may make your payment via Paypal, by check, or by phone (614) 220-5555. Make checks payable to Columbus Children's Choir. CCC singers, please make payment in choir office.

Columbus Children's Choir
760 East Broad St.
Columbus, OH 43205

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