"WAKE UP A MUSE" ART CLASSES

WITH GABRIELE DABASINSKAITE - REGISTRATION FORM

STUDENT INFORMATION
Name Name First Last
Date Of Birth Date Of Birth / MM / DD YYYY
Age
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
PARENT / GUARDIAN NAME
Name Name First Last
PRIMARY PHONE PRIMARY PHONE - ### - ### ####
Email
EMERGENCY CONTACT ( Name & Phone)
MEDICAL INFORMATION
DOES YOUR CHILD HAVE ANY ALLERGIES?

DOES YOUR CHILD HAVE ANY ALLERGIES? YES NO
IF YES, PLEASE SPECIFY ALLERGIES:
DOES YOUR CHILD HAVE ANY SPECIAL MEDICAL, MOBILITY, MENTAL OR HEALTH CONCERS?

DOES YOUR CHILD HAVE ANY SPECIAL MEDICAL, MOBILITY, MENTAL OR HEALTH CONCERS? YES NO
IF YES, PLEASE SPECIFY DETAILS:
CLASS SCHEDULE

Children aged 5-12 years old:
WEDNESDAYS 5:00–6:00 PM

Children aged 9-16 years old:
MONDAYS 5:30 - 7:00 PM
WHICH CLASS ARE YOU REGISTERING FOR?
CLASS FEES & PAYMENT INFO:

THE COST FOR EACH CLASS IS $40 PER STUDENT.
YOU MAY PAY IN ADVANCE FOR THE WHOLE SEMESTER, THEN A CLASS IS $25 PER STUDENT.
PAYMENT METHOD

PAYMENT METHOD Zelle Check Cash
Payable to: Gabriele Dabasinskaite
Zelle: justgaba@yahoo.com
BOOK CLASSES - DEPOSIT PAYMENT

TO RESERVE YOUR CHILD'S SPOT FOR THE NEW SEMESTER, PLEASE PAY A DEPOSIT OF 100$. THIS AMOUNT WILL BE APPLIED TOWARD YOUR CHILD'S TOTAL CLASS FEES.

IF YOU ARE PAYING FOR A SINGLE CLASS, PLEASE PAY $40 BY ZELLE TO GABRIELE DABASINSKAITE JUSTGABA@YAHOO.COM ( Please add child's name and details)
PAYMENT CONFIRMATION

PAYMENT CONFIRMATION I understand that this deposit in non-refundable and secure my child's registration.
PHOTO & ARTWORK USE:

PHOTO & ARTWORK USE: I GIVE PERMISSION FOR PHOTOS OR VIDEOS OF MY CHILD AND THEIR ARTWORK TO BE USED FOR PROMOTIONAL PURPASES ( Social media, websites, etc) I DON'T GIVE PERMISSION FOR MY CHILD PHOTOS & VIDEOS TO BE USED, ONLY ARTWORK FOR PROMOTIONAL PURPASES ( Social media, websites, etc)
Date Date / MM / DD YYYY
PARENT/ GUARDIAN SIGNATURE

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
STUDIO LOCATION

All classes take place at:
St. John Lithuanian Ev. Luth. Home Church
7214 S. Cass Ave., Darien, IL 60561 ( Door Nr#2 )
Contact: Gabriele Dabasinskaite
☎️ 1.630.670.0445 (text or call)

"WAKE UP A MUSE" ART CLASSES

"WAKE UP A MUSE" ART CLASSES

STUDENT INFORMATION

PARENT / GUARDIAN NAME

MEDICAL INFORMATION

CLASS SCHEDULE

CLASS FEES & PAYMENT INFO:

Payable to: Gabriele Dabasinskaite Zelle: justgaba@yahoo.com

BOOK CLASSES - DEPOSIT PAYMENT

STUDIO LOCATION

Payable to: Gabriele Dabasinskaite
Zelle: justgaba@yahoo.com