Name ____________________________________________ Age (if under 18) _______

Address ________________________________________________________________

City _________________________________ Zip _______________________________

Phone ____/______/__________ DOB ________________

Class Title _________________________________ Day _____________ Time ________

Class Title _________________________________ Day _____________ Time ________

TOTAL : $ _______________

What school does your child attend? ___________________________________________

How did you hear about Art Academia? ________________________________________

EMERGENCY INFORMATION

Name: __________________________________________________________________

Phone:

Home (______) _________________

Business (______) _______________

Cell (______) __________________