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Art Class Registration Form Please print out, fill in form, and mail with payment to: Prairie Winds Art Center 112 West 3rd St. Grand Island, NE 68801 |
Student's Name: ____________________________________________________________________________ Address: _________________________________________________________________________________ City, State, ZIP: ____________________________________________________________________________ Student's Age (if registering for elementary or middle school classes): ____________________________________ |
Please circle class desired: |
Elementary Summer 2010: Session 1 (June 7-10) Session 2 (June 14-17) |
Elementary Fall 2010 Middle School Fall 2010 Adult and High School Summer 2010 Adult Fall 2010 |
For Elementary, Middle School, and High School, please provide the following information: Parent or Guardian's Name: ___________________________________________________________________ Address: __________________________________________________________________________________ Phone Number: _____________________________________________________________________________ For all students, please provide the following information: Person to contact in case of emergency: ___________________________________________________________ Relationship to student: _______________________________________________________________________ Phone Number: _____________________________________________________________________________ Signature of Parent or Guardian (for Elementary, Middle School, High School): _________________________________________________________________________________________ Date: ____________________________________________________________________________________ |
For Prairie Winds Use only: Date Paid: _________________________________________ Type of Payment Received: ____________________________ Invoice Number: ____________________________________ |