BLUESHINE ART CLASS Registration Form
Student’s Name __________________________ Boy ______Girl______
Physical Address:
Street: _______________________________City: __________State: _____
Postal code: _______
Mailing Address (If Different):
Street: _______________________________City: __________State: _____
Postal code: _______
E-Mail Address ___________________________
Birth Date _________________ Present School Grade __________
Mother/Guardian ______________________ Home # ____________
Work # _______________
Father/Guardian _____________________ Home # ______________
Work # _______________
In the event of an emergency, whom do we call if we cannot reach you?
Name: _________________________ Relation: ______________
Phone #:_______________
Name: __________________________Relation: ______________
Phone #:_______________
Medical or other information we need to know: (include food allergies)
Who may pick up this child at the end of each class?
Name: _________________________________ Relation: ______________
Phone #:_______________
Name: _________________________________ Relation: ______________
Phone #:_______________
Written notice is required if your child is to leave with persons other than ones designated above.
Registration Fee: ($85.00 for 4 Saturdays -$185 for March Break Fashion Art Camp)
PAID: $_____.00
Method of payment (please circle):
CASH
CHECK (made payable to "Charlotte Hamilton")
PAYPAL(can use credit card, account: charlottah@rogers.com)
1. I hereby give permission for my child to participate in this program and to participate in outdoor activities
(Neighbourhood nature walks etc.).
2. Appropriate behaviour and respect for staff, property, and other children must be demonstrated by participants at all times. Failure to behave appropriately will result in dismissal from the program.
3. Your signature also gives the Bluehine Art approval to use photos of your children in promotional brochures, news articles, or other literature published by or for the Art Class.
My signature below is indicative of the fact that I have read and understood the information contained herein and agree to comply with same.
In consideration of the opportunity afforded to the undersigned to participate in any Art Class activity, the undersigned hereby knowingly, freely, and voluntarily waives any right or cause of action against Blueshine Art, its officers, agents, and/or employees arising out of any claim whatsoever as a result of any injuries to body, life, limb, or property arising from participation in the hereinafter described activity.
The undersigned shall save harmless the Blueshine Art from and against all judgments, orders decrees, attorney’s fees, costs, expenses, and liabilities arising from or out of such claim, investigation, or defence thereof which may be entered, incurred, or assessed as a
result of the foregoing.
Signature _____________________________
Parent of _____________________ Date ____________
