IS Kids Class Registration Form

Please print out this page, fill out the form and send/drop off along with a $50 deposit (a check made out to “Imagination Station”) to our Chocolate Factory location (54 Elizabeth Street, Red Hook, NY 12571):

Child’s Name: ____________________________________________
Child’s Nickname: ________________________________________
Child’s Age: _________________ Birthday: ____________________
Gender:    Female   OR    Male  OR   Other
Address: ________________________________________________
Parent/Guardian: _________________________________________
Relationship: ____________________________________________
Home Phone: ____________________________________________
Work Phone: _____________________________________________
Cell Phone: ______________________________________________
E-mail: __________________________________________________
Class you are registering the above child for
(pls indicate the day or days of the week you’d like them to attend):
_________________________________________________________

I, the undersigned, agree to submit a $50 deposit and to pay the IS class fee ($25 per class) plus materials fee ($20 per month) either in two installments before the start of both semesters OR monthly, on or before the first of each month.

__________________________________
Parent/Guardian Name

__________________________________
Parent Guardian Signature

__________________________________
Date