Online Class Registration Form

Today's Date*

Class(es) Attending and Start Date(s)*

Class	Start Date

Click the plus icon to enter additional classes/start dates.

Student Name*

First Last

Student Age*

Is this student homeschooled?

(Applies to child or teen student only.)

Yes
No

School District

(Applies to child or teen student only.)

Does the student qualify for free or reduced lunch?

(Applies to child or teen student only.)

Yes
No

Parent/Legal Guardian Name*

First Last

Please enter the parent/legal guardian name if student is a minor.

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone*

Email*

Enter Email Confirm Email

Would you like to be added to our email newsletter?*

Yes
No

Please check any item we need to be aware of. (This information will be kept confidential and is important for us to know.)

Allergies
Medication Needed
Behavior
Medical Issues
Other

If you checked any options above, please explain

Emergency Contact

Please list at least one emergency contact.

First Emergency Contact Name*

First Last

Relation*

Phone*

Second Emergency Contact Name

First Last

Relation

Phone

ArtFusion 19464 reserves the right to take pictures of students and/or students’ work for promotional materials.*

Yes, you may use photos of me/my child.
No, please do not use and photos of me/my child.

Class Policies*

By checking here, I acknowledge I have read and understood the class policies.

Consent and Release

On my own behalf or on behalf of my minor child (hereinafter referred to as “Student”), I hereby allow such Student for whom I am the legal guardian, to participate at an ArtFusion 19464 Art Class (hereinafter referred to as “Art Class”) sessions. In consideration of ArtFusion 19464 making this opportunity available to the Student, I hereby agree to release, indemnify and hold harmless ArtFusion 19464 (and their officers, employees, agents, volunteers, and Board Members), from and against any and all claims, demands, liabilities, losses or expenses, including attorney fees, and including injury to Student or other party, associated with Student’s participation in Art Class (including but not limited to those arising in connection with field trips, and any transportation to and from such field trips, the use of the School’s equipment or facilities, and those arising from any act or omission of third party due to student’s own conduct). I further agree that is any part of this agreement is found by a court or other appropriate authority to be invalid, the remainder of the agreement nevertheless will appropriate authority to be invalid, and the remainder of the agreement nevertheless will remain in full force and effect.

Consent and Release Acknowledgement*

I acknowledge that I have read and understand this Consent and Release, and voluntarily agree to be legally bound by its terms.

Medical Waiver*

I hereby grant ArtFusion 19464 (and their officers, employees, agents, volunteers, and Board Members), permission, at their discretion, to seek and authorize emergency medical treatment for myself or my child and I hereby agree to assume all medical costs incurred. I have included any additional medical information that ArtFusion 19464 needs be aware of in this form.

Additional Information

How did you hear about ArtFusion 19464?

Online search
Friend
Walking by
Other

If you chose Other, please elaborate.

If you were referred to us, whom can we thank?

Would you consider volunteering for our non-profit art center?

Yes
No

In what capacity could you best assist?

Additional Comments

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