Registration Forms

2012 REGISTRATION FORM
First name:
Last name:
Birthday/Age of child:
Guardian's Names:
Guardian's Phone/Cell Phone:
Emergency Contacts and Phone #'s:
Guardian's Email:
Street Address:
City/State/ZIP:
Please list all adults allowed to pick up child:
Please list any allergies or other important medical info:
Child's Pediatrician Name/Phone#:
Insurance Company/Policy #:
Class Name/Session:
Class Day/Time:
2nd Class Name/Session:
2nd Class Day/Time:
Fee Enclosed: Min. $50/non-refundable dep.
PAY WITH CREDIT CARD! By entering your credit card info and your name as it appears on the card, you are giving your legal signature for the charge to go through as of today's date.  How did you hear about us:	Please enter the type of credit card, credit card numbers, date of expiration, name as it appears on the card, amount wished to charge (min. $100), and the 3 security #'s.
Please type name of person if referred:
Please list anyone you would like to refer along with contacts:
	Important Information:  A non-refundable $50.00 deposit (payment towards tuition) is due when you register for the class and should be paid in the form of a check, cash or credit card.  This guarantees your space in the class. Any remaining tuition is due the first day of class. Unfortunately, tuition can not be refunded or prorated due to absences or illness unless agreed upon in writing with Megan Mingone prior to registration. However, tuition may be prorated for late enrollment. Credit vouchers may be given if extenuating circumstances require withdrawal from the class. These will be considered on an individual basis. Sibling Discount: Siblings simultaneously enrolled in classes (except preschool) receive a 10% discount off one tuition.  All Preschool and Homeschool classes require a $50 yearly supply fee (not a deposit) which does not get applied towards tuition, this is a seperate supply fee. Education PlayStation, Staff, or Teachers are not responsible for any injuries that children may incur during any classes.  Please make checks payable to: (DO NOT SEND CASH IN MAIL) Education PlayStation, Inc. Mail Check and Completed Form to: Education Play Station, Inc. 127 Summer Street Adairsville, Georgia 30103 Or contact us by: Phone 770-877-9105/ Fax 770-877-9106/ email educate@educationplaystation.com I understand and agree with the above information.
Please put any additional comments or questions in this area:
Comment/Question:
Best way to contact you:	Email address Mailing address Phone

REGISTER TODAY!