Community

Registration Form

Student Name____________________________

Age/Birthday_____________ Grade____

Art Class___________ Day___ Time___

EMERGENCY INFORMATION:

Parent/Guardian___________________

Address__________________________

City_________________ Zip_________

PH #:Cell________________________ Home____________Bus.____________

Email:___________________________

Doctor______________ Phone_______

Emergency Contact__________________________

Phone___________________________

Allergies or other information:_______

________________________________

I hereby give the Art Room staff permission to see that my minor child receives medical treatment in an emergency.

I have read, understood and agree to the Art Room enrollment and tuition policy.

Signed___________________________

I am enclosing payment for $_________

Checks payable to: HAA Art Room/Sherry Harig

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and Bring it to First Visit

Fall Schedule

September 2010