1st Student’s Name_________________________________________
Birthday__________________________________Age:___________
Class___________________________________________________

2nd Student’s Name_________________________________________
Birthday__________________________________Age:___________
Class___________________________________________________

Emergency Information

Parent/Guardian________________________________________________
Address______________________________________________________
City_________________________________________________________
State______________________ ZIP Code______________________________ EMail address: _________________________________________________
Phone: Home__________________________________________________
Cell ________________________________________________________
Emergency Contact:_____________________________________________
Phone:______________________________________________________
Any Allergies or other medical issues that we should know of? ___________________________________________________________
___________________________________________________________

How did you hear about Karen’s ART Zone? ____________________________ __________________________________________________________

I have read and understood the enrollment and refund policy. I hereby give Karen’s ART Zone staff permission to see that my minor child receives medical treatment in an emergency.

Signed_________________________________________________
Date__________________________________________________

Tuition
1st Student $ ________________
2nd Student $________________
Annual Registration Fee $ ___25.00______ NO REG FEE for Summer Camps
Total Enclosed $ ________________