Muse Squad Registration Form
Chapter (Town of Class)
example: New Milford
Student Information
Full Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number (Optional)
Please enter a valid phone number.
Home Address
Parent/Guardian Information
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to Student
Photo Release: As part of our creative writing program, we may take photographs or videos of students during class activities, events, and workshops. These photos/videos may be used for promotional purposes, including but not limited to marketing materials, social media posts, websites, or newsletters related to the program. By checking "I consent" below, you grant permission for your child's image and/or likeness to be used in such materials.
I consent to the use of my child's image for promotional purposes as described above.
I do not consent to the use of my child's image for promotional purposes.
Emergency Contact
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Payment
Payments of $350 can be mailed by check to Muse Squad PO Box 564, Ridgefield, CT 06877 or brought to the first class.
Date and Signature
Today's Date
-
Month
-
Day
Year
Date
Digital Signature: By digitally signing your name below, you acknowledge that your digital signature has the same legal effect and enforceability as your handwritten signature. You agree that your digital signature is an authentic representation of your intent and authorization, and you understand that it carries the same rights, obligations, and consequences as a physical signature.
Continue
Continue
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