St. Rita Youth Choir Registration

Mother's Name REQUIRED Please fill out this field. Please enter valid data.

Cell Phone (Mother) REQUIRED Please fill out this field. Please enter a phone number.

Email (Mother) REQUIRED Please fill out this field. Please enter an email address.

Father's Name REQUIRED Please fill out this field. Please enter valid data.

Cell Phone (Father) REQUIRED Please fill out this field. Please enter a phone number.

Email (Father) REQUIRED Please fill out this field. Please enter an email address.

Student's Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Number of Children Registering REQUIRED Please fill out this field.
Student Information 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Height for Grades 5-8 (Feet & Inches) Please enter valid data.
- School Attending Fall 2017 REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Does student have previous choir experience? REQUIRED Yes No Please fill out this field.
- If Yes, where? Please enter valid data.
- Does student play a musical instrument? REQUIRED Yes No Please fill out this field.
- If Yes...How many years and what instrument? Please enter valid data.
- After Rehearsal, Student will be: (Check one) REQUIRED Dismissed to St. Rita Extended Day Picked up Please fill out this field.
- If child is being picked up, please list the names and phone numbers of those allowed to pick up your child. Please enter valid data.
- Allergies (Medicine, Food, etc.) Please enter valid data.
- Special Needs/Medication: Please enter valid data.
- (Authorization of Consent to Treat Minor) I am the Parent/ Guardian/Conservator and as such do hereby authorize St. Rita Catholic Community, its leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold harmless the Parish and the Diocese of Dallas, their offices, directors, employees, youth ministry leaders, volunteers, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
- Authorization of Consent to Treat Minor Yes No
Student Information 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Height for Grades 5-8 (Feet & Inches) Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Does student have previous choir experience? REQUIRED Yes No Please fill out this field.
- If Yes, where? Please enter valid data.
- Does student play a musical instrument? REQUIRED Yes No Please fill out this field.
- If Yes...How many years and what instrument? Please enter valid data.
- After Rehearsal, Student will be: (Check one) REQUIRED Dismissed to St. Rita Extended Day Picked up Please fill out this field.
- If child is being picked up, please list the names and phone numbers of those allowed to pick up your child. Please enter valid data.
- Allergies (Medicine, Food, etc.) Please enter valid data.
- Special Needs/Medication: Please enter valid data.
- (Authorization of Consent to Treat Minor) I am the Parent/ Guardian/Conservator and as such do hereby authorize St. Rita Catholic Community, its leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold harmless the Parish and the Diocese of Dallas, their offices, directors, employees, youth ministry leaders, volunteers, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
- Authorization of Consent to Treat Minor Yes No
- School Attending Fall 2017 REQUIRED Please fill out this field. Please enter valid data.
Student Information 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Height for Grades 5-8 (Feet & Inches) Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Does student have previous choir experience? REQUIRED Yes No Please fill out this field.
- If Yes, where? Please enter valid data.
- Does student play a musical instrument? REQUIRED Yes No Please fill out this field.
- If Yes...How many years and what instrument? Please enter valid data.
- After Rehearsal, Student will be: (Check one) REQUIRED Dismissed to St. Rita Extended Day Picked up Please fill out this field.
- If child is being picked up, please list the names and phone numbers of those allowed to pick up your child. Please enter valid data.
- Allergies (Medicine, Food, etc.) Please enter valid data.
- Special Needs/Medication: Please enter valid data.
- (Authorization of Consent to Treat Minor) I am the Parent/ Guardian/Conservator and as such do hereby authorize St. Rita Catholic Community, its leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold harmless the Parish and the Diocese of Dallas, their offices, directors, employees, youth ministry leaders, volunteers, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
- Authorization of Consent to Treat Minor Yes No
- School Attending Fall 2017 REQUIRED Please fill out this field. Please enter valid data.
Student Information 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Height for Grades 5-8 (Feet & Inches) Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Does student have previous choir experience? REQUIRED Yes No Please fill out this field.
- If Yes, where? Please enter valid data.
- Does student play a musical instrument? REQUIRED Yes No Please fill out this field.
- If Yes...How many years and what instrument? Please enter valid data.
- After Rehearsal, Student will be: (Check one) REQUIRED Dismissed to St. Rita Extended Day Picked up Please fill out this field.
- If child is being picked up, please list the names and phone numbers of those allowed to pick up your child. Please enter valid data.
- Allergies (Medicine, Food, etc.) Please enter valid data.
- Special Needs/Medication: Please enter valid data.
- (Authorization of Consent to Treat Minor) I am the Parent/ Guardian/Conservator and as such do hereby authorize St. Rita Catholic Community, its leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold harmless the Parish and the Diocese of Dallas, their offices, directors, employees, youth ministry leaders, volunteers, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
- Authorization of Consent to Treat Minor Yes No
- School Attending Fall 2017 REQUIRED Please fill out this field. Please enter valid data.
Student Information 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Height for Grades 5-8 (Feet & Inches) Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Does student have previous choir experience? REQUIRED Yes No Please fill out this field.
- If Yes, where? Please enter valid data.
- Does student play a musical instrument? REQUIRED Yes No Please fill out this field.
- If Yes...How many years and what instrument? Please enter valid data.
- After Rehearsal, Student will be: (Check one) REQUIRED Dismissed to St. Rita Extended Day Picked up Please fill out this field.
- If child is being picked up, please list the names and phone numbers of those allowed to pick up your child. Please enter valid data.
- Allergies (Medicine, Food, etc.) Please enter valid data.
- Special Needs/Medication: Please enter valid data.
- (Authorization of Consent to Treat Minor) I am the Parent/ Guardian/Conservator and as such do hereby authorize St. Rita Catholic Community, its leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold harmless the Parish and the Diocese of Dallas, their offices, directors, employees, youth ministry leaders, volunteers, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
- Authorization of Consent to Treat Minor Yes No
- School Attending Fall 2017 REQUIRED Please fill out this field. Please enter valid data.
Student Information 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Height for Grades 5-8 (Feet & Inches) Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Does student have previous choir experience? REQUIRED Yes No Please fill out this field.
- If Yes, where? Please enter valid data.
- Does student play a musical instrument? REQUIRED Yes No Please fill out this field.
- If Yes...How many years and what instrument? Please enter valid data.
- After Rehearsal, Student will be: (Check one) REQUIRED Dismissed to St. Rita Extended Day Picked up Please fill out this field.
- If child is being picked up, please list the names and phone numbers of those allowed to pick up your child. Please enter valid data.
- Allergies (Medicine, Food, etc.) Please enter valid data.
- Special Needs/Medication: Please enter valid data.
- (Authorization of Consent to Treat Minor) I am the Parent/ Guardian/Conservator and as such do hereby authorize St. Rita Catholic Community, its leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold harmless the Parish and the Diocese of Dallas, their offices, directors, employees, youth ministry leaders, volunteers, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.
- Authorization of Consent to Treat Minor Yes No
- School Attending Fall 2017 REQUIRED Please fill out this field. Please enter valid data.

Doctors's Name REQUIRED Please fill out this field. Please enter valid data.

Doctor's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Health Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Policy Number REQUIRED Please fill out this field. Please enter valid data.

Insurance Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Media Consent: I hereby grant permission to St. Rita Catholic Community to allow my above-named children to be photographed and/or interviewed.It is my understanding that these photographs and/or interviews or portions thereof will be used for public view. I agree to participate in this project without financial remuneration, and I understand that this releases St. Rita Catholic Community and the Diocese of Dallas from any future claims as well as from any liability arising from the use of said photographs and/or interviews.

Media Consent REQUIRED Yes, I give my consent No, I do NOT give my consent Please fill out this field.

We agree to read and sign the Student Parent Agreement. Please bring the Student/Parent Agreement form to the first day of rehearsal. You can download the agreement on the right side of this webpage. REQUIRED Agree Please fill out this field.