Jen's Creative Kids

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Please fill out and mail or bring the completed form with your check payable to:

Jen’s Creative Kids, 293 Washington St. Suite 1B, Norwell, MA, 02061

Young Artist’s Name___________________________________________ Birth Date (M/D/Y)__________________

Parents Name(s)____________________________________________________________________________________

Address_________________________________________ City/State________________________ Zip______________

Home Phone Number___________________ Cell Phone Number___________________ Business____________________

Emergency Contact Person & Phone Number(s)____________________________________________________________

Pediatrician____________________________________________________ Phone_______________________________

Please List all allergies________________________________________________________________________________

Please let me know anything about your child that would be helpful. _____________________________________________

_________________________________________________________________________________________________

Class Selection Monday Tuesday Wednesday Thursday Friday
           
           

Amount Paid For Class(es):__________________

Please Circle One:  (Names of children will never be used for publication.)

Signature/Date________________________________________________________________________________________

Release Agreement:

Although every effort is made to provide a safe environment, I recognize there is always a risk of accident. If necessary, I authorize Jen’s Creative Kids to administer first aid and /or medical treatment for my child. Students are expected to carry their own accident and medical insurance. I agree to be responsible for any medical bills incurred resulting from illness or injury during my child’s participation at Jen’s Creative Kids. I further release Jen’s Creative Kids from any and all liability and/or claims or damages arising out of personal injury of any kind. I understand and have read all the information contained within.

Signature________________________________

 

Printed Name_____________________________

 

Date________________________