PGC Singer Registration

Singer First Name: Singer Last Name: Singer Preferred Name: Birth Date(MM/DD/YYYY): / / Singer Email Singer Phone New Singer Month/Year Singer Joined Choir Name (2020-2021 Season) Cantabile Dolce Harmonia Ethnicity School Name School Grade (2020-2021 School Year) School District School Type T-Shirt Size (sizes run small) Child Small Child Medium Child Large Child XL Adult Small Adult Medium Adult Large Adult XL Adult XXL Singer lives with? Parent/Guardian Name 1 (First and Last) Parent/Guardian 1 Email: Parent/Guardian 1 Phone: Preferred Texting number Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Permission to release address and phone number for possible car pool contact? Place of Employment Position/Title (if applicable) Parent/Guardian Name 2 (First and Last) Parent/Guardian 2 Email Parent/Guardian 2 Phone: Preferred Texting Number Would you like Parent 2 to also receive emails and phone messages? Place of Employement Position/Title (if applicable) Emergency Contact-other than primary adult Emergency Contact Phone Emergency Contact Relationship to Singer Singer Physician Physician Phone Singer Insurance Company Singer Insurance Policy/Member ID # Singer Insurance Group # Insurance Subscriber Name Insurance Subscriber Employer Special Needs Please explain special need if necessary. Singer has or uses the following health aids: If there are other heath aids, please leave a description Vaccinations Up to Date Chronic illness or other health concern. Please explain if necessary. Dietary Needs/Preferences Asthma Asthma Management Allergies Allergy Management Is your allergen life threatening? Allowed to Swim Swim Skill Level Beginner Intermediate Advanced Allowed Medications Would you like to add an additional amount to your one time or monthly payment to contribute to needs-based financial aid at PGC? This additional amount would be entirely tax-deductible. If yes, how much and how often would you like to contribute? (Please enter a dollar amount and either "one time" or "monthly") Payment preference (Tuition)-Select up to 2 options Preferred Payment method Name on Account: Name of Bank: Account Number: Routing Number: Name on Card: Card number: CVV (Verification Code) Billing Zip Code: How did you find PGC? If referred by a singer, teacher, or public event, who/what event? Photo Consent Financial liability and refund policy Medical care and responsibility policy Electronic Signature Captcha