~Print & Take Form to Kent County Parks & Recreation to Complete
Registration~
REGISTRATION FORM (One Form Per Person)
Date
New Student
Returning
Student
NAME
Date Of Birth:
AGE:
ENROLLING IN CLASS(S)
(Check All That Apply):
□Kidz Praize!
(7-9)
□ Jr. Praize & Spiritual Movement (7-9) □ Holy Hip Hop (10&up)
□Spiritual
Movement (10&up) □Spiritual Movement (Adults) □Other:
PARENT/GUARDIAN (If
Under 18)
HOME ADDRESS
HOME PHONE
WORK PHONE:
E-MAIL:
CELL PHONE:
EMERGENCY CONTACTS (List two that are available
during your scheduled class time).
NAME:
NUMBER
NAME: NUMBER
Special circumstances,
needs or physical challenges? Please Explain. This will better equip us to service
you or your child so that they can get the maximum experience:
I
Agree and Understand The Following: (Initial Each):
_____1.
Shekinah Arts! is not responsible for the supervision of the participant(s) either
before or after the participants’ regularly scheduled class time.
_____2. Shekinah Arts! reserves the right to photograph and videotape programs and participants
for training, advertising, promotional activities, and any other lawful purposes. If
I do not want my or my child’s photo used, I understand that it is my responsibility to notify Shekinah Arts! in writing.
_____3. I am aware of and voluntarily accept all risks that my child or I may be involved
with in participation of activities with Shekinah Arts! and will not hold Shekinah Arts!, its workers or volunteers responsible
for bodily injury or loss of any kind. It is understood and agreed that Shekinah Arts!, its employees and agents, cannot be
responsible for any aggravation or injury caused as a result of a pre-existing physical defect; including but not limited
to, allergies. Shekinah Arts! will be notified of any such defects or sensitivities
in writing prior to enrolling in this program.
_____4. Tuition is due at time of registration class.
Enrollment will be considered complete once a student has paid tuition and attended class. Credits or refunds will
not be issued due to missed classes. A $25 charge will be applied to all returned checks.
I
have read and understand the Shekinah Arts! policies.
Student or Parent/Guardian
Signature
DATE
PAYMENT INFORMATION
Registration Form
& Payment can be completed at or mailed to KCPR, P.O. Box 67, Worton, MD 21678. Please make checks or money orders
payable to: “Tamika Sudler-Shekinah Arts.”
**Shekinah Arts!
Is an independent agency and is NOT affiliated with KCPR
.
------------------------------------------------------------OFFICE
USE ONLY----------------------------------------------------------------------
Date Reg. Form Received:
# of Classes Enrolled:
Date Tuition Paid:
~Print & Take Form to Kent County Parks & Recreation to Complete
Registration~