REGISTRATION

 

Peace Camp Registration Form

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To enroll, please call for reservation and then print out this form, fill in the information, and mail
it with your payment to the address indicated below. (303) 530-2662

Abbey Fine Arts

5607 Mt. Audubon Pl

Boulder, CO 80503

Peace Camp 2005 Registration Form

 

Child’s First Name: ________________________ Last Name: ___________________________

Date of Birth: ______ /______/ _____ Age: __________

Address: ___________________________________Apt # ____ City: _____________________

Zip Code: ______________ Phone: ______ – _____– ________ Email Address: _____________

Session(s): ____June 6 – 10 ____June 13 – 17 ____June 20–June 24 ____ June 27 – July 1 ____July 11 – 15 ____ July 18 – 22 ____July 25 – 29 ____August 1 – 5 ____August 8 – 12 ____August 15 – 19

Mother’s Name: __________________________ Phone: ______– ____ – _____________

Work Phone: _____ – _____– ________ Cell Phone: ______– ____ – _____________

Father’s Name: __________________________ Phone: ______– ____ – ______________

Work Phone: _____ – _____– ________ Cell Phone: ______– ____ – _____________

Emergency Contact: ___________________________ Phone: ______ – ______ – ___________

Family Doctor:________________________________ Phone: ______ – ______ – ___________

Health Insurance Co and #: _______________________________________________________

Anything we should know about your child’s health?

____________________________________________________________________________

If at any time medical treatment is necessary for my child, I give consent for treatment to be given. I understand that every effort will be made to contact parent/guardian prior to emergency treatment.

Signature of Parent: ________________________________________Date: ________________

I give consent for Peace Camp/Barrows School of the Arts to take photographs which may be used for promotion purposes.

Signature of Parent: ________________________________________Date: ________________

Tuition: (# Weeks x $195), ______________ Extended Care: (# Weeks x $75), _____________

(10% Discount on tuition before April 15 th)

Total Amount ___________ Check Enclosed ___________ Credit Card ______Visa ______MC

Name on Card _______________________________ Expiration Date: ____ /____/____/_____

____ /____/____/____/____/____/____/____/____/____ /____/____/___ /____/____/____ /____

Signature: _______________________________________________ Date: ________________

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