Sculpture - Ceramics - Pottery Wheels  - Tuition - Art Therapy - Studio Artemis
Enrolment Form
     Studio Artemis
 Enrolment Form Child 2017
 
Class……………………………………… Day 1/Time…………………
 
Class……………………………………… Day 2/Time……………………
 
Child Name……………………………................................................ 

Child Name……………………………................................................ 

Parent Name…………………................................................   (if under 18)
 
 Age………….. School Attended ..............................................(if under 18)
 
Address………………………………………………………………………
 
 …………………………………………………………….Postcode………
 
Tel: Home…………………Mobile……………………Work………….......
 
Email………………………………………………………………………….
 
Emergency Contact

Name…………………………….................................

Emergency 

Tel……………….........................................................................
 
Asthma/Allergies to Nuts Dogs or Other: (circle)

...........................................................................................................................

Epi Pen required  yes  /  no

Disabilities

....................................................................................................

How did you hear about us?

........................................................................

 I wish to pay by:   Cash     Credit Card         Visa          MasterCard 
 
 Amount:  $.....................   Paid in Full by Cash  Direct Deposit  Credit Card  Gift Voucher
 
Card Number .... …. …. …./…. …. …. …./…. …. …. …./…. …. …. ….
 
 Expiry Date …. …./…. ….  Cardholders Name………………………….
 
 Cardholders Signature………………………...................Date………….
 
 Office Use Only:
 
 Receipt Number……………………………. 
 
 Date…………………………….