Wednesday Night Educational Series Registration Form

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:

Emergency Contact Individuals:

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

I DO consent to and authorize the use and reproduction by PSL Services/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.