IRVING After School Student Registration Form FALL 2017

Student Registration Form

Student First Name *

Student Last Name *

Class Day

Home Phone *

Home Street Address *

City *

State *

Zip *

Parent's Name *

Parent's E-mail *

Phone Number *

Emergency Contact Name *

Emergency Cell Phone *

Student is in Grade *

Student Birthday

Date

Release of Liability : I hereby agree to be responsible for the conduct and actions of my child and release STEAM Works Studio and employees from any claims and demands that may occur during participation in classes which may arise from incidents/accidents involving my child, held on the premises of STEAM Works Studio , to the extent allowed by law.

Signature *

Date *

Date

Permission for Release of Content for STEAM Works Studio publications, website, and social media including Facebook and Twitter, for participants in classes, camps, and activities. I hereby consent that my child’s image, and likeness, as shown in videos, photographs, film, and/or electronics images and/or audio recordings of my child’s voice many be used by STEAM Works Studio for purposes of event documentation, media coverage, and promotion, and are the sole property of STEAM Works Studio .

Signature

Date

CHILD WILL ATTEND: *

STEAM Programs (Grade K-3) 3 months $ 297.00

STEAM Programs (Grade K-3) 6 months $ 590.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Thank you very much for registering!

STEAM Works Studio - Irving

(972) 746-4493
www.steamworksstudio.com/irving
steamirving@steamworksstudio.com
https://www.facebook.com/SteamworksatIrving

After-School Enrichment Classes