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English
Design Laboratory - Registration Form
Student
______________________________________Age _____M/F
Date_________
My
school_____________________________________________________
Class, Day
&
Time________________________________________
Parent
Name___________________________
E-mail___________________________
Address________________________________
City_______________
Zip_______
Home
#_________________Work
___________________Cell__________________
Emergency
contact – Name_______________________________________
Relationship
_________________________Phone_____________________
Birthday
Month/year _________________
Special Medical
Information_______________________________________
I hereby give
permission for my child_______________________________________to
participate at English Design Laboratory classes, workshops, camps,
labs, and
other lab class activities. I
do also
release English Design Laboratory and the owners, operators, and all
instructors, from any and all liability due to accident or injury that
may
result from participation in any classes, workshops, camps, labs, and
other lab
class activities.
Parent/Guardian
Signature
Payment
information
$30.00
Registration Fee Annual________
$30.00 deposit
towards class cost (non-refundable) ________
Check________
Cash___________
Paypal
(at
Website)_________________
Paypal
through Website (process fees applied) Visa, Mastercard
and American Express accepted.
Do you allow
English Design Laboratory to use your child’s
picture for advertising material specifically for classes?
Yes________
No_________
Parent/Guardian
initials____________
How did you
here about us? Newspaper/Magazine Article ___
Advertisement______________
Friend_________________Flyer/Mailer______________Other____________
______________________________________________________________________
Paid in
Full__________________
Date__________________
English Design Laboratory, Inc.
3660
Canton Road, Suite 210, Marietta, Ga 30066
Phone: (770)
924-2977 fax
(770) 924-8189
http://www.EnglishDesignLab.com
email
kenglish@englishdesignlab.com
Rev. 9/08