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 indicate class desired:
Elementary School; spring 2012
Middle School; spring 2012
High School/Adult: Watercolor Class with Jean Cook OR Oil/Acrylic with Ken
Bassett
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: ____________________________________