"Brush Painting Circle" - Registration Form

Name of student: ___________________________________________________________________________

Date of Birth: _____________________________

Address: _________________________________________ City: _________________ Zip: _______________

Email address: _____________________________________________________________________________

* Name of parent of legal guardian (for student participant under the age of 18 only): _________________________

For myself, the undersigned, and the minor listed above, of whom I am the parent or legal guardian, I agree to hold harmless Amy Da-Peng King an dthe Redwood City Art Center for any injury, loss or liability, which results from participation in this program.
Signature is required by each registrant.

Signature: _____________________________________________________ Date: _______________________

Class Name: _____________________________ Class Date/Time: ________________________ Fee $_______