Brushstrokes Studio / Summer Camp 2010
Registration Form
School age children should be registered for classes that correspond to the grade level in which they will enter this coming fall. Each course is designed for the abilities of a particular age range. Please feel free to call 817-731-9249 for more information.
Print this page on your computer, and after completing, mail to:
Brushstrokes Studio
4400 W. Vickery Blvd.
Fort Worth, TX 76107
Name of Child ___________________________________________________________________________________ Circle one: Male Female Child’s Age Now Home Address ____________________________________________________________________________________ City _________________________________________________________
Zip _______________________________ Home Telephone __________________________________________________________________________________ Mother/Guardian __________________________________________________________________________________ Daytime Phone _________________________________________________________________________________ Cell Phone ____________________________________________________________________________________ Other Phone ___________________________________________________________________________________ Father/Guardian ___________________________________________________________________________________ Daytime Phone _________________________________________________________________________________ Cell Phone ____________________________________________________________________________________ Other Phone ___________________________________________________________________________________ Email: _________________________________________________________________________________________ Name of person other than parent/guardian to be contacted in case
of emergency: _____________________________________________________________________________________________ Relationship of this person to child _________________________________________________________________ Phone ________________________________________________________________________________________ Does your child have any special medical needs, allergies or conditions?
_____No _____Yes, please explain: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ I understand that Brushstrokes Studio will arrange any necessary
emergency medical treatment in the event the parents or other
authorized person listed above cannot be reached. Photographs
of classes and students may be taken by Brushstrokes staff to
use for archival and promotional purposes. A full refund can be
given if the cancellation is made no less than 14 days from the
day the class begins. No refunds will be made after this deadline. Parent/Guardian Signature ___________________________________________________________________________ Date ____________________________________________________________________________________________ Below, please list the class/classes in which you would like to
enroll your child. Registration confirmation and a receipt will
be sent by mail. 1)______________________________________________________________________________________________ 2)______________________________________________________________________________________________ 3)______________________________________________________________________________________________ 4)______________________________________________________________________________________________ 5)______________________________________________________________________________________________
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