IS Summer Art Camp 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: __________________________________________________
Week(s)/Session(s) Requested
(pls indicate dates & times, i.e. mornings or afternoons):
________________________________________________________
________________________________________________________
________________________________________________________

I, the undersigned, agree to submit the $50 deposit, plus full summer tuition before the start of classes.

__________________________________
Parent/Guardian Name

__________________________________
Parent Guardian Signature

__________________________________
Date