Wednesday Night Educational Series Registration Form

First Name

Last Name

Address

City/Town

State

ZIP

Phone #

Series you would like to attend

Why would you like to participate in this series?

Student's Signature

Class series fee is $20 to be paid until a week before class begins

Emergency Contact Information:

Student's Name

Parent/Guardian Name

Parent/Guardian Email

Emergency Contact Individuals:

1. Name

Phone #

Relation to student

2. Name

Phone #

Relation to student

3. Name

Phone #

Relation to student

Other Information:

Please list any of the student’s allergies or any other information it would be helpful to know in case of an emergency

Parent/Guardian Signature

Date

Signature of Participant if over 18, or guardian

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