Name First Name Last Name Address Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Email 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 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. Date Signature of Participant if over 18, or guardian
