Art Therapy Registration Form

Art Therapy Registration Form

Fall Semester
Tuesday Schedule
Date - 09/24/2024 -12/17/2024
Time - 2:00- 3:00 PM
Check-in Intro

Thursday Schedule
Date - 09/26/2024-12/19/2024
Time - 5 - 6:00 PM

Registration fee $20 if registered after 9/10

Group Sessions Only 8 participants/class

1 hour session

Ages 4-10 years

$15/class

$25/week (1 month commitment)

Includes all materials
Student Information
Name

First NameLast Name
Age
Gender

MaleFemale
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis/IEP (If yes please list. We may need a copy)
School Level/Grade
Write something about yourself/child
Parent/Guardian Information

For minors (below 18 years of age)
Parent/Guardian Name

First NameLast Name
Phone Number
Email
example@example.com
Relationship
Other
How do you learn about this online art class?

FacebookTwitterInstagramYouTubeSearch EngineOnline AdsReferralOther
Do you want to add enroll more students?

YesNo
Additional students
Payment & Confirmation
Please pay on website: sensoryfunandplayroom.com/book-online (Art Therapy Class)
prevnext( X )
Tuesday (single class)
$15.00 Quantity



Thursday (single class)
$15.00 Quantity



1 week
$25.00 Quantity



Total

$0.00
Please only sign if you're 18 years old and above otherwise, leave it blank and have your parent/guardian signed the next signature field.
Signature of Student

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Date Signed

MonthDayYear
Date
Parent/guardian Signature

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Date Signed

MonthDayYear
Date
If you have any questions, please email or call us using the details below:

Sensory Fun & Playroom sensoryfunandplayroom@gmail.com. (260)444-6009

sensoryfunandplayroom.com
Should be Empty:

Art Therapy Registration Form

Student Information

Parent/Guardian Information

Other

Payment & Confirmation