I.S. 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
Address: ___________________________________________________________________________
If student is child or teen,
Parent/Guardian: _______________________________________________________________
Relationship: _____________________________________________________________________
Cell Phone #1 (best number to reach): ____________________________________________________________________
Cell Phone #2: ____________________________________________________________________
Home Phone: ______________________________________________________________________
E-mail: ______________________________________________________________________________
Class you are registering the above student for
(pls indicate the days of the week and the dates/sessions):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

 

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 ($25 per month) either in three  installments before the start of each semester in Sept, Jan and April.  If paying monthly, on or before the first class. 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

 

______________________________________
Date