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____________ ______________________________________________________________________

Official use

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