Blue Giraffe

Blue Giraffe Registration Form
CHILD INFORMATION:
Child Name*

First NameLast Name
Age
Child Name*

First NameLast Name
Age
PARENT/GUARDIAN INFORMATION:
Parents/Guardians Names*

First NameLast Name
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
E-mail*
Emergency Contact Name (other than primary contact)*

First NameLast Name
Emergency contact Phone Number (other than primary contact): *

Area CodePhone Number
About your child: Allergies, Special needs (physical; developmental; behavioral/emotional; sensory). Please write anything you believe is important to know about your child. This information helps our staff to do their best to accommodate all of our students particular needs.
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
By clicking the box below, I hereby Give Permission for photographs in which my child's ART WORKS appear on the Blue Giraffe's website

I agreeI disagree
LATE PICK-UP POLICY FEE AND PROCEDURE: Up to 15 minutes: Automatic flat $15.00 late fee is charged. After 15 minutes: Automatic flat $25.00 late fee is charged*

I agree
By clicking the box below, I hereby acknowledge that there are NO refunds or make-ups for missed classes, except Art classes. I understand that this is a program that exist as one whole program and can not be divided by individual days or classes.*

I agree
Comments

Registration for a program at Blue Giraffe$55.00

Total $0.00

Credit Card

Signature

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Age
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Blue Giraffe Registration Form

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

Credit Card