Class Day & Time _________________________________________

Child's Last Name _________________________________________

Child's First Name _________________________________________

Child's Birthdate   __________________________________________

Address  _________________________________________________

________________________________________________________

Phone Number________________________________________

Parent Name ____________________________________________

Parent Name _____________________________________________

Email Address _____________________________________________

Does your child have any allergies?

_________________________________________________________

Please choose one of the following and sign:

_____ I give permission for my child's photo to be used for marketing purposes.

_____ I DO NOT give permission for my child's photo to be used for marketing purposes.

___________________________________                                    
Signature &  Date