Territory Six Sewing Academy – Student Registration Form

Territory Six Sewing Academy – Student Registration Form

Please complete all sections and sign where required.
Student Information
Student Name

First NameMiddle NameLast Name
Preferred Name (if different)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Grade
School Attending
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship to Student
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Preferred Method of Communication
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to Student
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Any Allergies or Medical Conditions?
Allergies, Medical Conditions, or Physical Limitations
Currently Taking Medications?
Medications Affecting Participation
Sewing Machine Information
Will Student Bring Their Own Sewing Machine?
Machine Brand/Model
Machine Model (Optional)
Does the Machine Work Properly?
Membership Options
Choose Your Membership
Weekly Attendance Days Request (Will be notified to confirm availability)
Session Time Request ( Spaces are limited. Will be notified to confirm availability)

Other
Alternate Days and Times if days requested not available
Authorized Pick-Up Persons
Name

First NameMiddle NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Notes
Name

First NameMiddle NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Notes
Name

First NameMiddle NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Photography & Media Release
Photography & Media Release Permission
Parent Initials for Media Release
Liability Acknowledgement
Liability Acknowledgement - Agreement
Parent/Guardian Signature
Liability Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Agreement
Parent Agreement Items

Other
Parent Initials
Parent Name (Print)

First NameLast Name
Parent Signature
Parent Agreement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Promise
Student Promise Items
Student Name

First NameLast Name
Student Signature
Student Promise Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Notes
Should be Empty:

Territory Six Sewing Academy – Student Registration Form

Student Information

Parent/Guardian Information

Emergency Contact

Medical Information

Sewing Machine Information

Membership Options

Authorized Pick-Up Persons

Photography & Media Release

Liability Acknowledgement

Parent Agreement

Student Promise