Student Registration Form

 

Please complete the form below to register up to 4 students from the same family.

Name of Guardian (if Registrant is under 18) *
Name of Guardian (if Registrant is under 18)
Address *
Address
Phone (Primary) *
Phone (Primary)
Type *
Phone (Secondary) *
Phone (Secondary)
Type *
Emergency Contact Person *
Emergency Contact Person
Emergency Phone
Emergency Phone
Number of students registering for lessons
Student (s) Name *
Student (s) Name
Date of Birth *
Date of Birth
Student (s) Name
Student (s) Name
Date of Birth
Date of Birth
Student (s) Name
Student (s) Name
Date of Birth
Date of Birth
Student (s) Name
Student (s) Name
Date of Birth
Date of Birth
In case of accident
I authorize appropriate personnel to secure for the children listed above (under age 18) the services of emergency transportation, a physician, a dentist, or a hospital in the event of accident or illness. I will be responsible for payment of all services. This consent for treatment is in effect only during the actual program hours and dates that the above-named child is participating in lessons at MaroneyArts Art Studio.
Physician *
Physician
Physician phone *
Physician phone
Dentist *
Dentist
Dentist phone *
Dentist phone
Photo Release
I, the undersigned, grant Anastasia Maroney permission to use any pictures taken in public view of the registrant individually, or any in which the registrant appears in whole or in part. Additionally, I grant permission to use pictures taken of artwork created by the registrant. I understand that these pictures may be reproduced in print and electronic media specifically to promote MaroneyArts and any of its programs. I waive any right to inspect or approve said pictures, or any captions or accompanying texts that may be used in connection with them, or to approve the use to which said material may be applied.
Registration and Cancellation Policies
● Billing is done monthly approximately one week prior to the first lesson in each month. All requests for changes in lesson times must be made prior to payment of an invoice. Changes to class times can NOT be guaranteed after an invoice is paid. No refunds will be made after an invoice is paid. ● Billing is done electronically, via secure online invoicing and is payable via credit card prior to the first lesson of the month. ● A small supply fee will be added to the monthly invoice and will cover regular, in-class materials. Additional supplies above and beyond the usual may be necessary and can be supplied by the teacher for a small cost or by the student. ● Email is my primary means of communicating with you. A confirmation email will be sent upon receipt of registration. ● One class per month may be made up in the event of illness. Please contact me as soon as possible prior to the lesson in order to reschedule.
Date *
Date