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» Wednesday Night Educational Series Registration Form
Wednesday Night Educational Series Registration Form
Name
*
Address
*
City
*
State
*
Zip Code
*
Series you would like to attend
*
Email
*
Phone #
*
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
*
I DO consent to and authorize the use and reproduction by STRIVE of any and all photographs and any other audio visual materials taken of participant for promotional materials, educational activities, exhibitions or for any use for the benefit of the program.
Date
*
Year
Year
2017
2018
2019
2020
2021
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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11
12
13
14
15
16
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18
19
20
21
22
23
24
25
26
27
28
29
30
31
Signature of Participant if over 18, or guardian
*
