Jana Bednarkova Kenney

Name *

First Name

Last Name

*

Boy

Girl

Parent Info *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Home *

(###)

###

####

Phone Work

(###)

###

####

Phone Cell *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Authorized Pick-Up Person *

First Name

Last Name

First Name

Last Name

Image of Art work Release

I give permission for my child's artwork to be used by Village Arts and Education Foundation on its website and any other related publicity, including print and/or broadcast media.

Yes

No

Image of my Child Release *

I give permission for my child's photograph to be used by Village Arts and Education Foundation on its website and any other related publicity, including print and/or broadcast media.

Yes

No

Kids Like Clay Refund Policy *

I understand and agree to the following: Upon enrolling in a class with the Kids Like Clay, an agreed upon class fee will be required by check or credit card. The student is entitled to full refund of this fee two weeks or more prior to the date of the scheduled class. In the event a cancellation occurs by the student less than two weeks prior to the scheduled class date, the full amount of the deposit is non-refundable. 4. In the event the class is cancelled by Kids Like Clay, the student is entitled to a full refund.

I have read and I understand the Cancelation Policy

Today's Date *

MM

DD

YYYY