Student's First Name:               Student's Last Name:      

Student's Age:    Student's DOB:    E-Mail Address:

Parent's First Name:                   Parent's Last Name:

Home Phone:    Work Phone:    Cell Phone:

Home Address:    City:    State:    Zip:

ART-N-SOUL Galerie requires all children be signed in and out by an authorized adult.  Please list the name(s) of an adult authorized to sign for your child below:

Authorize Adult #1:                 Authorize Adult #2:

In case of an emergancy please contact:     Phone:  

Please list any food allergies and/or known medical conditions your child may have below:

We accept all forms of payment: cash, checks, money orders (payable to Uche Amadi) and credit cards.  You have the option to mail, fax or personally hand deliver your payment.  You can also pay on-line by using Pay-Pal.  All payments must be received no later than June 17th, 2006.  No application will be processed, without payment being submitted and verified first.  Click here to make a payment on-line if you are a Harston Wood's resident.  For non-Harston Woods residents, please click here.

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