THE ALTADENA ARTS COUNCIL

 ________________________________________
Student’s Name

Student’s Date of Birth ______/______/______

Parent (s) Name

_____________________________________

Address______________________________

_____________________________________
City State Zip

(_____) ___________(_____)_____________
Phone # & Alternate Phone #
_____________________________________
E-mail Address

EMERGENCY INFORMATION

_____________________________________
Full Name of Emergency Contact

Tel. # ____________/Alternate ___________


PLEASE READ THE FOLLOWING AND THEN SIGN AND
DATE BELOW.

A complete application must be submitted to Altadena CAC on
or before the first day of class. A complete application includes
full payment of tuition and a completed registration form signed
& dated by a parent. Classes are filled on a first come basis. If a class is filled or cancelled the applicant will receive a full refund.

Refunds are not available after October 24, 2011. A processing
fee may be charged for multiple program changes or refunds.
All requests for change of program must be received in writing with authorized signature.  Altadena CAC reserves the right to discontinue a student’s participation in the 2011 Fall Program, without refund or credit, due to improper behavior I give Altadena CAC the right to reproduce my child’s image and artwork created during the program for the purposes of program publicity or fundraising.


____________________________________________________
STUDENT/PARENT(IF MINOR) SIGNATURE & DATE

Course Title_______________________________

Age Group______ Date __________________

Course Title_______________________________

Age Group______ Date__________________

Course Title_____________________________

Age Group______ Date___________________

Course Title_______________________________

Age Group______ Date__________________


Total Tuition Enclosed $_____________

Total Materials Fee Enclosed $_____________

CAC Membership Fee Enclosed $_____________
(optional)

TOTAL AMOUNT ENCLOSED $_____________

METHOD OF PAYMENT

Cash $_______ Check #___________________

Credit Card #__________________________

          AMEX VISA DISCOVER MASTERCARD
         
          Expiration Date_______________

          Cardholder Signature______________________

If paying via check, money order or cash., send payments
to The Altadena Arts Council, P.O. Box 6571, Altadena, CA. 91003.  OR, pay in person at CAC, Loma Alta School Center (Loma Alta and Canon Drive), 626-797-5798

If paying via Pal, simply click on the PayPal Buy Now and have
your payment registration fees instantly credited.