One Art Class
Student Name
First Name
Middle Name
Last Name
Age
Parent Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
Emergency Contact Name
*
Emergency Contact Phone Number
*
E-mail
*
Date of the class/classes
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
*
I agree
Date
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One Art Class
$
49.00
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Total
$
0.00
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