912 Riverside Drive, San Jose CA 95125 (408) 975-9987
PRINT AND FILL OUT — SEND COMPLETED FORM AND CHECK TO ADDRESS ABOVE
Please write in classes by title:Class Title:_______________________________________ Amount:__________
Student's Name: _________________________________________ Age ______
Address: _________________________________________________________
City:________________________________ State:______ Zip: _____________
Phone#:_________________________ Cell#:___________________________
E-mail:___________________________________________________________
Parent/Guardian Names: ____________________________________________
Emergency Contact:________________________________________________
Emergency Phone#:________________________________________________
Allergies/Medical Problems/Concerns?___________________________________
_________________________________________________________________
** If you have referred someone to our classes this session please let us know by putting their name here______________________________________________
If you took a discount who did you refer this session?______________________
REQUIRED FOR REGISTRATION: Please Read Below and Sign
In consideration for the acceptance of my application for participation in ArtHouse Kids classes, I hereby waive, release and discharge Marylea Adams, Julie Stover and any member of their staff or families from and against any liability for any loss, personal injury, including death and property damage that may have arisen out of or in any way connected with my (my child's) participation in the aforementioned activity. Furthermore I assume all responsibility and agree to indemnify Julie Stover, Marylea Adams and Art House Kids and staff for any loss, damage or injury to myself (my child) which may have been caused by negligence, or any act, of any person connected in any way with the aforementioned event. I have read the above and understand its meaning and voluntarily sign it.
____________________________________________________________
Signature of Parent/Guardian
Send in form/check to: ARTHOUSE KIDS 912 Riverside Dr. San Jose, CA 95125 View & register online: www.arthousekids.com or call: 408-975-9987