Brush & Paisley In-person Art Class Registration

Brush & Paisley

In-Person Art Class Registration Form
Name *

First Name Last Name
Age *
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent's Name *

First Name Last Name
Parent's Email *
example@example.com
Parent's Phone #: *

Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Phone #: *

Area Code Phone Number
Preferred Payment Method *
Select # of Classes *

6 Thursday classes from Sep 1-Oct 6 - $180 Thursday, Sep 1 - $35 Thursday, Sep 8 - $35 Thursday, Sep 15 - $35 Thursday, Sep 22 - $35 Thursday, Sep 29 - $35 Thursday, Oct 6 - $35
Does your child have any allergies? If yes, please specify *
Does your child have any health condition, which we need to know *
Photos

Brush & Paisley (Raksha Soni) has my permission to take, use, and publish photos and/or videos of my child for publicity purposes. This includes, but is not limited to ads, website, slideshows, social media, flyers, and other promotional material.
Information Sharing

Brush & Paisley (Raksha Soni) has my permission to include my child's name, address and phone number on a list distributed to other students in his/her group.
By submitting this form, I state that I am the parent/legal guardian of the student and abide by the class policies. I understand and agree to the following:

In case of emergency, I hereby authorize my child to be treated by certified medical personnel; and, if deemed medically necessary to hospitalize my child, I hereby give permission to the attending physicians to secure proper treatment, to order injections and/or anesthesia and/or surgery for my child named above. I also authorize the release of medical information that may assist in providing appropriate care.
Acknowledge *

I have read, understood, and accepted the rules for the program.
Parent's Signature *
Print Full Name
Once you submit your registration, we will contact you shortly to make your payment.

Thank you!
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