2008-2009 Northwest Art Center Registration

Today’s Date:

 
Student:                                                                                                                                                                                                
                                                    ^{Last                                                                     First}
Address:                                                                                                                                                                                               
                                                                                            ^Street                                                                                                         
Address:                                                                                                                                                                                               
                                                ^{City                                                                                      State                    Zip}                                   
Email Address:                                                                                                                                                                                    
 
Home Phone:                                                    Cell Phone:                                                    Work Phone:                                    
 
If student is under 18 please fill out the following:   
 
                Age:                       Birth date:                                                                                                                                             

                Mother or Guardian:                                                                                                                                                           
                                                                                                                        ^{Last                                                                                               First}
                Father or Guardian:                                                                                                                                                             
                                                                                      ^{Last                                                                                               First}
                Additional Family Members Enrolled:                                                                                                                             
 
 
Does the student have any life threatening Medical Conditions or allergies that we should be aware of?
   NO        YES
If yes, please describe:                                                                                                                                                                       
 
In addition,     I DO  or     I DO NOT   give authorization for the Northwest Art Center to authorize medical treatment for the above named student if they find it necessary.
 
Please tell us how you found Northwest Art Center:                                                                                                                   

Please mark your Art Interests:

 Adult watercolor	 Adult oil	 Adult acrylics	 Girl Scout workshops
 Adult mixed media	 Adult jewelry	 Adult drawing	 Children’s art classes
 Adult pottery	 Adult printmaking	 Art docent workshops	 Children’s pottery classes