Course Code & Title *

Age/Birthdate (Child Only) *

Adult's Name (Children's Classes) *

Address With Zip *

Home Phone *

Email (To Confirm Registration)

Student Name *

Day/Time *

Relationship to child *

Cell Phone *

Best Place To Reach You *
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Adults Authorized To Pick Up Your Child

Anything Else We Should Know

I GIVE PERMISSION FOR THE USE OF PHOTOS AND VIDEO OF MYSELF AND / OR MY ARTWORK IN MEMORIAL ART GALLERY PUBLICATIONS.
I GIVE PERMISSION FOR THE USE OF PHOTOS AND VIDEO OF MY CHILD AND / OR MY CHILD’S ARTWORK IN MEMORIAL ART GALLERY PUBLICATIONS.
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