Choir, Strings and Handbell Registration 12-Week SemesterSeptember 3 …………. First day of classesNovember 19 ………… Final day of classesNovember 19 ………… Fall Concert If you have previously created a parent account, and want to use that information on this form, be sure to log in first.Please submit one form per child.Username (pre-populated & hidden)Student InformationName* First Last Birthday* MM DD YYYYGradeAgeSexMaleFemaleAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Family InformationParent/Guardian #1Name* First Last Relationship to student*Email* Phone*See Parental Involvement (link opens in new window) on the General Information page for full descriptions, then check one or more below:Parental Involvement (choose at least one)* Class Assistant Monthly Cookies Outfit HelpParent/Guardian #2Name First Last Relationship to studentEmail PhoneSee Parental Involvement (link opens in new window) on the General Information page for full descriptions, then check one or more below:Parental Involvement Class Assistant Monthly Cookies Outfit Help Medical InformationEmergency Contact NameEmergency Contact PhonePlease list all allergies, medical conditions and medications: Code of Conduct and Acknowledgement of Parent Responsibility in Open EnvironmentI, the Student, promise to conduct myself in an appropriate manner, being respectful to my teacher, and fellow students. I understand that if I cannot conduct myself appropriately, I may be asked to leave the class without refund.I, the Parent/Guardian, understand that Campus Bible Church (both Palm and Maple campuses) is an open environment, accessible to the public. I understand that I am responsible to ensure the safety of my children before and after class while on campus, and I understand that Inspire One and class teachers are not responsible for my children's safety outside of class.By checking the box below, both Student and Parent understand, agree with, and choose to abide by these policies.* We agree with the above statementPermission SlipGood for all events through December 2019.My child has my permission to attend all activities connected with his/her class during the dates set forth above. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases his/her teacher, Inspire One and its staff, and Campus Bible Church of any liability related to any injury to said child. I have legal custody of the student named above, a minor, and have given my consent for him/her to attend the aforementioned events. I understand that there are inherent risks involved in any ministry, and I hereby release Campus Bible Church, Inspire One, its teachers, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. I also agree to bring my child home at my own expense should he/she become ill or if deemed necessary by his/her teacher or by an Inspire One staff member.* I agreeMedia Permission SlipI give permission to include my child in any videos and/or photographs taken during the course of my child’s involvement* I agree I DO NOT agree, except for group photos and group videos.Signature*Use your mouse to sign on a desktop, or your finger on a tablet or mobile device. This is a legally binding signature.Date Date Format: MM slash DD slash YYYY Date for Late RegistrationThis not-displayed field is needed for being able to conditionally display the early/late pricing and the late fees. DO NOT DELETE! Date Format: MM slash DD slash YYYY Class TypePlease select a class type.ChoirStringsHandbellsArt Classes- Select One -S161AEACA-Cartooning 1st-5th GradeS161AEACB-Cartooning 6th-12th GradeS161AECA-Genesis Beginnings 1st-5th GradeS161AECB-Genesis Beginnings 6th -12th GradeDance Classes- Select ClassS16DMBBA-Ballet- Melody (6-9)S16DMBBB-Ballet- Melody (10-14)S16DESIA-Beginning IrishS16DESIB-Intermediate IrishS16DARC-Creative DanceS16DARBA-Ballet-Aubree(Ages 6-8)S16DARBB -Ballet-Aubree (Ages 8-10)S16DARBC-Ballet Aubree (Ages 11+)S16DTSJA -Jazz/Lyrical (Ages 6-8)S16DTSJB-Jazz/Lyrical (Ages 9-11)Choir Classes (Early Registration Discount)- Select One -F19BC-Beginning Choir (grades K thru 2) - $55F19CHC-Children’s Choir (grades 3 thru 6) - $75F19CC-Concert Choir (grades 7 thru 12) - $115F19CME-Concert Choir & Guys' Ensemble (grades 7 thru 12 by audition) - $165F19GE-Concert Choir & Girls' Ensemble (grades 7 thru 12 by audition) - $165Choir Classes- Select One -F19BC-Beginning Choir (grades K thru 2) - $80F19CHC-Children’s Choir (grades 3 thru 6) - $100F19CC-Concert Choir (grades 7 thru 12) - $140F19CME-Concert Choir & Guys' Ensemble (grades 7 thru 12 by audition) - $190F19GE-Concert Choir & Girls' Ensemble (grades 7 thru 12 by audition) - $190Language Classes- Select One -S16LKYA-Sign Language ASL-2A - $95S16LKYV-Sign Language Visual Sound - $70Strings Classes- Select One -F19SO - String Orchestra- $125F19SP - Private String Lessons - pay teacher directlyConfirmed Lesson Time*This registration form should only be completed if you have ALREADY worked out a private lesson time with Mrs. Clark. Please confirm: have you worked out a lesson time?YesNoPlease do not submit this form until you have a confirmed time with Mrs. Clark!Handbells Classes- Select One -F19HBB - Beginning Handbells- pay teacher directlyF19HBI - Intermediate Handbells- pay teacher directlyF19HBA - Advanced Handbells- pay teacher directlyPhotography Classes- Select One -S16PSRI-Intro to Digital PhotographyLate Registration Fee Price: $25.00 CouponIf you have more than 2 children in choirs, there is a $10 discount for each additional student. Please contact email@example.com for sibling coupon codes. Total $0.00 Credit CardAmerican ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Create an AccountWould you like us to create an account to save your basic information so that you can fill out this form faster next time? (If you get an error message about already having an account, it means that you have previously used your email on a user account for this site.)NoYesUsername*Choose a username for your account. A temporary password will be assigned, and you can change this in your profile. You should get an email from the site with your username & password. If you don't see this email in your inbox, be sure to check your spam folder!Update your info?Would you like to update the info in your user account with the information submitted in this form? A temporary password will be assigned, and you can change this in your profileYesNoNameThis field is for validation purposes and should be left unchanged.