DATE: _________________________________

NAME OF STUDENT _______________________________________________________________________________________________

Date of birth _________________________________________ (circle one) Male/Female ~ Right/Left handed

Your art interests___________________________________________________________________________________________________

Your School Board__________________________________________________________________________________________________

Full name(s) of Parent/Guardian _______________________________________________________________________________________

Full Address ______________________________________________________________________________________________________

Telephone-home_________________________Telephone-work_________________________Telephone-cell_________________________

Tel EMERGENCY CONTACT___________________________Name of emergency contact__________________________________________

Does student have any medical concerns or conditions we should be aware of

_________________________________________________________________________________________________________________

Age group student is registering in_______________SESSION #(s)_________

Class Location registering in ____________________________________________________

TOTAL FEE(S):___________________________USE ONE Registration Form per student please

Full Payment MUST be received by registration deadline.***NOTE MONTHLY DEADLINES***

MAKE CHECK PAYABLE TO: Art on the Brain Ltd.

MAIL TO: Suite 1600, 246 Stewart Green S.W., Calgary, Alberta T3H 3C8

For information call (403) 217-9975