FOR STAFF USE ONLY Program/date registered in:

NEW:

LOS PLENEROS DE LA 21
THE BOMBA & PLENA COMMUNITY WORKSHOPS

REGISTRATION FORM

PARTICIPANT/STUDENT INFORMATION (INFORMACION DEL ESTUDIANTE/PARTICIPANTE)

Last Name First BIRTHDATE (M/DD/YY):

Grade or Occupation: SCHOOL (NAME, CITY)

AGE

(BPCW ONLY)

GENDER

CONTACT INFORMATION (Complete all that apply)

Street Address City State APT # ZIP

PHONE (home) PHONE (work) EMAIL(s) PARENT/GUARDIAN or EMERGENCY CONTACT & RELATIONSHIP: ALLERGIES (FOOD OR OTHER):

PHONE (cell) PHONE (Emergency)

OTHER INFORMATION
How did you hear about BPCW? New to BPCW (Y/N) Special interest areas: Year(s) participated:

PARTICIPANT OR- PARENT /GUARDIAN SIGNATURE:

Full Name (Print)

RELATION TO STUDENT: INTERNAL USE ONLY: DISCOUNTS APPLIED: Deposit (pymt amt & date) PYMT 1 (amt & date) PYMT 2 (amt & date) PYMT 3 (amt & date)

Signature Full Name (Print) Date:

TOTAL COST:
BALANCE REMAINING