Alabama River Region Arts Center

300 West Tallassee Street Wetumpka, Alabama 36092

**** This form must be completed and signed by Parent or Legal Guardian Please Print**** Title of Club: Date of Class: Student's Name: Parent/Legal Guardian: Home Phone Mailing Address Work/Cell Phone: City E-Mail: State Zip Time of Class: Age: Instructor: Monthly fee:

Please list any medical conditions, allergies or special concerns we should be aware of:

In case of Emergency, contact (if parent cannot be reached): Phone Number: Office use only: Date Paid: Invoice #

Amount Paid: Member Y /N

(Circle One) Cash Check Charge

Please read the following terms carefully and sign: 1. Students must pre-register at least 1 week before the start of the monthly sessions. Guitar club is limited to the first 10 students, others will be put on a waiting list. If a student does not register before the deadline,(Last Thursday of the month) The student may be loose their spot and be placed on a waiting list. We will accept the first 10 students in each session. 2. Refund Policy: If student cancels, the pre-paid registration fee is non-refundable. (Unless we can fill the slot with another student) 3. Upon receipt of payment, you will receive club info 4. Mail registrations will be treated on first come basis. 5. In the unlikely event of a medical emergency, every possible effort will be made to contact the parent or guardian and medical assistance will be summoned. 6. Students may not arrive earlier than five minutes prior to class, and must be picked up no later than ten minutes after class has ended.

RELEASE OF LIABILITY: My signature acknowledges that I have read, and fully understand the ARRAC policies stated herein. I hereby release the Alabama River Region Art Center, its officers, members, volunteers, and class instructors from any and all claims for injury, loss, damage, or negligence; I may suffer as a result of participation in a class.

Signature of Parent or Legal Guardian Please mail or take this form & payment to: Alabama River Region Art Center, 85 Canal Cove, Wetumpka, Al 36092 Gallery Temp. Phone: 334-578-9485 (hours: Sat. 10-4, Sun. 12-4) Rev. Date: 08/08/2011 ds


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