2017 Fall Programming Registration Form

STUDENT CONTACT INFORMATION

Thank you for completing these important details. You will find class information in the next step.

Student's First Name *

Student's Last Name *

Under the age of 18? *

Yes

No

Student's Grade (2016/2017) *

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Please email me updates about this class

Are you a member of Aiken Center for the Arts? *

Yes

No

Which class offerings would you like to view?
(select all that apply) *

Youth Classes (pre-K - 12th grade)

Adult Classes (16+)

Adult Workshops (16+)

ADDITIONAL INFORMATION

Do we have your permission to photograph you/your child for our partner and promotional use? *

Yes

No

In the event of an emergency, do we have your permission to authorize transport to the hospital? *

Yes

No

Please indicate what course of action you would like taken: *

Please list any allergies or special conditions we should know: *

Would you like to list an emergency contact in the event of an emergency?
(NOTE: For students under the age of 18, we will contact the parent FIRST, then the emeregency contact if unsuccessful) *

Yes

No

Additional Comments:

EMERGENCY CONTACT INFORMATION

Emergency Contact's First Name *

Emergency Contact's Last Name *

Emergency Contact's Phone Number *

Relation to Student: *