18_RegForm

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egistration Registration Form Form

ater Street Water Studios, Street School Studios, of ArtSchool of Art

S. Water Street,160 Batavia, S. Water IL 60510 Street,Batavia, 630.761.9977 IL 60510 waterstreetstudios.com 630.761.9977  waterstreetstudios.com stions contact: Kari Questions Kraus,contact: DirectorKari of Education Kraus, Director  kari_l_kraus@sbcglobal.net of Education  kari_l_kraus@sbcglobal.net  info@waterstreetstudios.com  info@waterstreetstudios.com

me:__________________________________________________ Name:__________________________________________________ Contact # (_______) Contact _______-__________ # (_______) _______-__________

ress ________________________________________________ Address ________________________________________________ City_______________________________ City_______________________________

e________ ZipState________ _____________ Zip _____________ Email _______________________________________________________ Email _______________________________________________________ Student’s Name

Student’s Name Class Title

ease check if f allergies Please* check if f allergies*

Class Title Class Date(s) ClassCost Date(s) Student and session # if applicable and session # if applicable age (if

Cost

under 18)

Total:

Student age (if under 18)

Total:

hod of Payment: Method  Check of Payment: # _______  Check  Cash # _______  Gift Certificate  Cash _______  Gift Certificate  Other _______ _______ Other _______  Credit (if mailingregistration, Credit (if mailing pleaseregistration, see below) please see below)

Children’s Classes For Children’s Only: Parent Classes Contact Only: # (_______) Parent Contact _______-__________ # (_______) _______-__________

cial needs/concerns/requirements Special needs/concerns/requirements that we need to bethat aware weof: need ______________________________________ to be aware of: ______________________________________

_______________________________________________________________________________________ __________________________________________________________________________________________

_______________________________________________________________________________________ __________________________________________________________________________________________

Allergy information:________________________________________________________________________  *Allergy information:________________________________________________________________________

_______________________________________________________________________________________ __________________________________________________________________________________________

ve read, understand I haveand read, willunderstand abide by the andpolicies, will abide rules, by the andpolicies, regulations rules, of Water and regulations Street Studios of Water (on back) Street_____. Studios (on back) _____. initial here

initial here

es! I would liketoYes! volunteer, I wouldplease like tocontact volunteer, me please about volunteer contact me opportunities: about volunteer __________________________ opportunities: __________________________

For office use only:For Date office Received use only: ____/____/____ Date Received ____/____/____ Date Processed ____/____/____ Date Processed ____/____/____ Initials________ Initials________ _ _ _ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ _ _ _ _ _

ase note: CreditPlease Card information note: CreditisCard removed information from this is removed form and from shredded this form afterand processing shreddedforafter security. processing for security.

isa

 MasterCard  Visa

 MasterCard

Expiration Date________________ Expiration Date________________

dit Card # _____________________________________________________________ Credit Card # _____________________________________________________________ CVV # _____________ CVV # _____________

me as it appearsName on card as it(please appears print)__________________________________________________________ on card (please print)__________________________________________________________

dholder’s Signature Cardholder’s ________________________________________________________________________ Signature ________________________________________________________________________ rev08_10


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