One Try-Out Art Class
Student Name
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Middle Name
Last Name
Age
Parent Name
First Name
Middle Name
Last Name
Phone Number
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Area Code
Phone Number
Emergency Contact
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First Name
Last Name
Emergency Phone Number
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Area Code
Phone Number
E-mail
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example@example.com
Please contact us to check available days/time bluegiraffedc@gmail.com / 301-275-6768
Additional Comments, Concerns, Special needs: (physical; developmental; behavioral/emotional; sensory). This information helps our staff to do their best to accommodate all of our students particular needs.
Authorization for Medical Treatment: in the event that parents/guardians named on this form cannot be reached, I authorize officials of the Blue Giraffe Education Center to consent on my behalf, to provide emergency treatment for my child
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One Try-Out class
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