2017-18 Class Registration Signup Form

Art Classes

Registration Form 2017-18
Student Name

First NameMiddle NameLast Name
Gender
Grade
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Parent/Guardian 1

First NameMiddle NameLast Name
E-mail
Cell Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Parent/Guardian 2

First NameMiddle NameLast Name
E-mail
Cell Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Emergency Contact

Please list two alternative contacts if you cannot be reached in an emergency.
Contact 1

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Contact 2

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
MEDICAL CONSENT
I HEREBY GIVE MY PERMISSION TO THE STAFF OF ALEX'S ART STUDIO TO TAKE MY CHILD TO A LOCAL HOSPITAL EMERGENCY ROOM IF I CANNOT BE REACHED AND THAT ALL NECESSARY TREATMENT CAN BE GIVEN AT THAT TIME.
OTHER
ALLERGIES
EPI PEN
ASTHMA
PHOTO/VIDEO/SOCIAL MEDIA RELEASE

Pursuant to state and federal law, Alex’s Art Studio will not release any personally identifiable information without prior consent from the student’s parent or guardian. Personally identifiable information includes student’s names and grade levels, photo images, location and times of field trips, and awards and honors. Although the global accessibility of the Internet brings with it some inherent dangers, I would like to celebrate your child and his/her work. The law requires that we ask for permission to post any information about your child.
I/we grant permission for an identifiable photo image of my child along with his/her name and grade level to be published on the Alex’s Art Studio website and in local newspapers.You may not publish an identifiable photo image or any other personal information regarding my child on the Alex’s Art Studio website.

ALEX'S ART STUDIO

Registration 2017-18
Student Name

First NameMiddle NameLast Name
Classes are a 9 month program commitment. Registrations are processed in the order they are received, on a first-come, first served basis. (10 student per class limit)
I am registering my child for the following class.
Elementary Level (1st-4th grade)
Intermediate/Jr High Level(5th-8th grade)
High School Level (9th-12th grade)
Please type your name below that you acknowledge to have read and agree to the registration guidelines and policies.*
Classes are a 9 month program commitment. Registrations are processed in the order they are received, on a first-come, first served basis. (10 student per class limit) The registration fee will secure my spot in the class and includes art supplies for the 9 month program.
Payment for the entire month of art lesson is due at the first lesson of each month.
Please select *
prevnext( X )
Current Student Early Registration (May 1st - June 30th)$100.00

New Student Early Registration (June 1st - July 1st)$125.00

Registration (after July 1st)$150.00

Subtotal $0.00Tax $0.00Total $0.00
Should be Empty:

Art Classes

Emergency Contact

MEDICAL CONSENT

PHOTO/VIDEO/SOCIAL MEDIA RELEASE

ALEX'S ART STUDIO