MAP Arts Enrichment - Toddler Playgroup

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Singer's Name*

First Name

Last Name

Gender

Male Female

Ethnic Data*

Asian or Pacific Islander Black/African American Hispanic Native American White/Caucasian Other Decline to Answer

State and/or local grants require the choir to report ethnic data

Date of Birth*

Email*

Confirm Email *

Phone Number*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

County*

Emergency Contact Name*

First Name

Last Name

Emergency Contact Phone Number*

Media Waiver

This waiver gives permission for the use of name, images, pictures, and recordings of my child (stated previously) by the Indianapolis Children's Choir without compensation except as may be agreed in advance for certain projects, this permission being a waiver as to all choir functions regardless of payment or other benefits to the choir.

Date Agreed to Media Waiver*

: :

Agree to media waiver*

I agree to the media waiver

Name of your local newspaper

How did you hear about ICC?*

Please Specify

If not applicable, please write N/A

Medical Release and Information

In the unlikely event that my child becomes ill or is injured, and I cannot be immediately contacted at the time of an emergency, and if in the judgement of the staff of the Indianapolis Children's Choir immediate observation or treatment is necessary, I authorize and direct the staff to send my child (properly accompanied) to the hospital or physician most easily accessible. I also give permission for dispensing of over the counter medicines (i.e. Tylenol, Tums, Ibuprofen, etc.) as deemed necessary by the ICC staff or the designated medical personnel. I release the Indianapolis Children's Choir, their employees, and agents from any claim of liability in connection therewith.

Date Agreed to Medical Release*

: :

Agree to Medical Release*

I agree to the Medical Release

Please list any special health problems, allergies, and learning disabilities of singer*

Please list any dietary restrictions

Please list any medications being taken by singer*

Does your child require an epipen?*

Billing Information

Coupon code

Please be sure to click "apply"

Credit Card*

Expiration Date*

Card Verification Code*

Name on card*

First Name

Last Name

Billing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Tuition - $165 per year, nonrefundable* $

I would like to make a donation to the Indianapolis Children's Choir

Donation amount $

I would like to add a monthly donation to my tuition payment

Monthly donation amount $

Convenience fee* $

Total charge to your card* $

I, as parent or guardian, give permission for my singer to attend ICC's Arts Enrichment Toddler Playgroup with an adult caregiver

Date Agreed to Financial Policy*

: :