IS 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):

Student’s Name: _______________________________________________________________
Student’s Nickname: _________________________________________________________
Student’s Age: __________________________ Birthday: _________________________
Gender:    Female   OR    Male  OR   Other
Address: ___________________________________________________________________________
If students is child or teen:
Parent/Guardian: _______________________________________________________________
Relationship: _____________________________________________________________________
Home Phone: ____________________________________________________________________
Work Phone: ____________________________________________________________________
Cell Phone: ______________________________________________________________________
E-mail: ______________________________________________________________________________
Class you are registering the above student for
(pls indicate the day or days of the week and the dates/sessions you’d like them to attend):


I, the undersigned, agree to submit a $50 deposit and to pay the IS class fee. If registering for school year classes, I agree to pay $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. If registering for summer classes, I agree to pay the summer class total by the first class of the session.

Adult Student OR Parent/Guardian NAME


Adult Student OR Parent Guardian SIGNATURE