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Participant's Name
Participant's Date of Birth
Gender
Female
Male
Prefer not to state
Mailing Address
1st Parent/Guardian Name
Home Phone
Cell Phone
Work Phone
Preferred 1st Contact Number
Home Phone
Cell Phone
Work Phone
2nd Parent/Guardian Name
Home Phone
Cell Phone
Work Phone
Preferred 2nd Contact Number
Home Phone
Cell Phone
Work Phone
1st Pick Up/Drop off Individual's Name
Relationship to Student
Daytime Phone
Evening Phone
Also emergency contact?
Yes
No
2nd Pick Up/Drop Off Individual's name
Daytime Phone
Evening Phone
Authorizations
I authorize photography and videotaping of the above named participant, or any musical compositions he/she produces as part of enrolling in the program for Colour Outside The Lines Music Centre, for archival documentation purposes and to authorize publication of this material in any media, including my website for promotional or educational purposes
Yes
No
I have ensured that all the information given is accurate and up to date and that if there are any changes that it is my responsibility to inform the Colour Outside the Lines Music Centre
Yes
No
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