INSPIRED 2012 Supporting the MUSC Children’s Hospital Fund
3nd Annual INSPIRED
REGISTRATION FORM Parent’s Names: _____________________ Family Name
_______________________ and/or _____________________________ Parent’s First (w/Title) Spouse’s First (w/Title) (if applicable)
Home Address: _____________________________________________________________________________________ City/State/Zip_______________________________________________________________________________________ Please Circle Primary Contact Number and Contact Person Home Phone:_________________ Her Work Phone:______________ Her Cell:______________ Other Phone:_________________ His Work Phone:_______________ His Cell:______________ Email Addresses: Hers:___________________________________His:__________________________________
Please Enroll My Child(ren) Listed Below in the 2012 Inspired Program (All Children Must Be In The Same Immediate Family – Brothers & Sisters)
Child’s Name:_____________________________Age:______ DOB: Month_____Day_____Year______ Child’s Name:_____________________________Age:______ DOB: Month_____Day_____Year______ Child’s Name:_____________________________Age:______ DOB: Month_____Day_____Year______ Child’s Name:_____________________________Age:______ DOB: Month_____Day_____Year______ My donation for ___$65.00 for one child or ___$95.00 for two or more children made out to the MUSC Children’s Hospital Fund is enclosed. I understand that I will be called by Signature Photography to set up the Pre-Consultation appointment and the Session appointment and understand the terms stated in the “Just the Facts” document published on the “Inspired” Website. ______________________________________________ ________________ Parent Signature Date Please make your donation payable to the MUSC Children’s Hospital Fund and send it with this signed form to Inspired, c/o Signature Photography, 320 East Bay Street, Suite C, Charleston, SC 29401. Credit Card Information Type: ____________ Card Number: ______________________________________ Security Code: ____ EXP:____ Name on Card: _____________________ Billing Address of Card: ______________________________________ Questions? Please call the studio: 843-300-3333
Website Information: http://Inspired.SignaturePhotography.Biz