PCA Class Registration

PCA Class Registration

A separate registration form must be completed for each participant and for each individual class.
STUDENT INFORMATION:

(One student per form)
CLASS *
Student Name (preferred name for name tag) *

First Name Last Name
Date of Birth *

Month Day Year
(mm-dd-yyyy)
Preferred Pronouns *

she/her/hers he/him/his they/them/theirs

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Grade (2019/2020) *
Name of School *
Please share any information that will help us provide the best possible experience for your child (include things like: allergies, behavioral challenges, etc., or enter "none") *
PARENT/GUARDIAN (1) CONTACT INFORMATION:
Parent/Guardian Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone Number *
(123) 456-7890
Secondary Phone Number
E-mail *

Confirmation Email
Parent Guardian (2) Contact Information

(only need to fill out if another parent/guardian wants to receive all emails and Remind messages)
(2) Parent/Guardian Name

First Name Last Name

(2) Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

(2) Cell Phone Number
(2) Secondary Phone Number
(2) E-mail Address
example@example.com
(#1) : ALTERNATE PICK/UP & RELEASE

Please list any persons you authorize to pick up your child other than Parent/Guardians previously listed. ID required & must match the designated pick-up.
Name

First Name Last Name
Cell Phone Number
Secondary Phone Number
Relationship to Child
(#2) ALTERNATE PICK/UP & RELEASE
Name

First Name Last Name
Cell Phone Number
Secondary Phone Number
Relationship to Child
Please list any other persons who you give permission to pick up your child. Include name, cell phone number and relationship to your child.
Parent/ Guardian Initials:
By initialing above, I give PCA instructors and volunteers permission to release my child to the contacts listed and will notify the administration in writing if any changes occur.
Terms of Agreement: Photo Release

I hereby give permission for my child to be photographed during the PCA class. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/ or reports to our donors and for promotional purposed including flyers, brochures, newspaper and on the internet. His or her identity will not be disclosed.
I agree to the terms of the photo release agreement: *

Yes No
Parent Guardian Initials *
By initialing above, I certify that I agree (selected"yes") or disagree (selected "no") to the terms of the photo release agreement
How did you hear about PCA Classes?
Choose Payment Method *

PayPal on PCA Website Mail a Check
Signature Required:

**Pepperell Community Arts is not responsible for lost or damaged personal property. All events are subject to change.
Parent/ Guardian Signature *

Clear
Name of Parent/ Guardian signing *

First Name Last Name
Today's Date *

Month Day Year
Date
Should be Empty:

PCA Class Registration

STUDENT INFORMATION:

PARENT/GUARDIAN (1) CONTACT INFORMATION:

Parent Guardian (2) Contact Information

(#1) : ALTERNATE PICK/UP & RELEASE

(#2) ALTERNATE PICK/UP & RELEASE

Terms of Agreement: Photo Release

Signature Required: