Registration Cart
(707) 462-9370 • 145 E. Church St., Ukiah CA 95482 •
info@spaceperformingarts.org
SPACE Classes
-- Register Online on our Secure Server
Registration Cart
Please provide the following information for the
SECOND STUDENT you are registering:
If you are registering MORE that two students,
please fill in this form and submit it for each student you are registering after the first student.
[
*
] indicates required
*
Choose one:
New Student
Continuing Student
Please be sure to select the appropriate registration fee below.
STUDENT INFORMATION
*
Student's Name:
Street Address:
City, Zip:
Home Phone:
Birthdate
(M/D/Y):
Age:
School:
Grade:
REGISTERING PARENT/GUARDIAN INFORMATION
Check if this information is
Same as 1st Student's
then continue to "Emergency Contact"
-OR-
Check if address and phone is
Same as above Student's
then complete "Par./Guard. Name" and "Work Phone"
Par./Guard. Name:
Street Address:
City, Zip:
Home Phone:
Work Phone
EMERGENCY CONTACT OTHER THAN PARENT
Check if address and phone is
Same as 1st Students
then continue to "Additional Information"
Emergency Name:
Relationship:
Phone:
ADDITIONAL INFORMATION
Please tell us of any information about your child that will help insure a safe and succesful experience:
REGISTRATION FEES
*
Select the appropriate registration fee:
Registering 2nd student (or student other than 1st) for
ONE class: $10
Registering 2nd student (or student other than 1st) for
TWO classes: $5
Registering 2nd student (or student other than 1st) for
THREE or more classes: $0
IMPORTANT
RELEASE OF LIABILITY INFORMATION
: When we receive your online registration, we will e-mail our "Release from Liability" form to you for each student you are registering. Your child will be
required
to bring this signed form to the first class. Or you may come to the SPACE office prior to the first class and request a "Release from Liability" form to be signed.
