Student’s Name: ____________________________________________ |
School Name:
____________________________________________________ |
Age: __________________
Grade: _________________ |
Address: ___________________________________________________ |
City, State &
Zip: _________________________________________________ |
Home Phone: ________________Emergency
Phone: ______________
Cell Phone: _______________________________
Email Address: _____________________________________________
(for Manners I & II Children's classes only)
Which class day would you prefer?: ____ Wednesdays
____ Thursdays |
Food Allergy/Medical
Condition, if any: __________________________________________________________________ |
What
would you (or your child) like to gain from a class? __________________________________________________________________
__________________________________________________________________
__________________________________________________________________ |
Photo
and Video Release
We occasionally take group or candid photos during class
time and sometimes use them in our promotional materials. May we have
your permission to use you or your child in a photo or video strictly
for these purposes? ______Yes _______ No |
Today's Date:
_______________________________________
Name of parent or guardian, if student is a minor:
____________________________________________________________________ |
Signature of
student or parent/guardian:
____________________________________________________________________ |