ESG-TE-10-14

        Etiquette School of Grace Registration Form

First Name: ___________________            Last Name: ___________________                         MI: ______

 Birthday: _____/_____/__________             Gender:          _____ Male                ______ Female

                   mm         dd                    yyyy

Father's Name: ___________________________               Birthday: _____/______/_____________

                                                                                                                                                                mm          dd            yyyy

Mother's Name: ___________________________             Birthday: _____/______/_____________

                                                                                                                        mm          dd            yyyy

Other family members:

            Name                                                  Birthday                                              Relationship 

 __________________________        ______/_______/_______                  ______________________

                                                                mm            dd                     yyyy                        

__________________________        ______/_______/_______                  ______________________

                                                               mm            dd                      yyyy

 School Attending: __________________________________          Grade Level: _________________

 Home Address: _____________________________________________________________________

                                    Number & Street                                     City                                         State                        Zip Code

 Home Phone Number: ______/_____/_________     Cell Phone Number: ____/_______/__________

 I am using ___ My Own, or ___My Parent's e-Mail Address: ______________________________

 I like: (select all that apply)

 ____Dancing              ____Swimming           ____Reading              ____Camping             ____Golfing

 ____Video Games      ____ Barbie & Dolls  ____Biking                 ____Writing                ____Tennis

 ____Play Day             ____Action figures     ____ Art                      ____ Team Sports      ____Singing

 ____Instruments        ____Skate boarding   ____Gymnastics         ____Cheer Leader     ____Music

 My favorite food:  ________________________     My favorite place:  ________________________

 Any food allergies? (If yes, please specify):______________________________________________

 My best friend's name is _____________________________.       Age ________________________

 When growing up,

I want to be a _______________________. And my parents want me to be a __________________.

  Circle three choices for class days:

 Monday          Tuesday          Wednesday     Thursday        Friday             Saturday         Sunday           

Conditions of Enrollment

 1.    The Director reserves the right to deny, cancel, modify or suspend the enrollment of a child deemed in the child's best interest, or if the child��s physical or mental condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the school.

2.    Parent(s) shall fully disclose in advance any pre-existing physical or mental illnesses, allergic conditions or disabilities of the child. Parent(s) releases Etiquette School of Grace from any and all claims, causes, or liabilities and agrees to indemnify and hold Etiquette School of Grace harmless in connection with any damages sustained as a result of any such non-disclosure. Director shall be permitted access to medical or psychological information of such condition(s).

3.   Our nurturing, professional staff will make every effort to assure each child��s adjustment to the class environment.

4.    Parent(s) gives permission for the school to use any photographs, slides and videotapes in which his/her child/children may appear for advertising and publicity purposes.

5.   Parent gives permission for child/children to participate in off-premises class activities and field trips. (Parents will be notified in advance of these events.)

6.    No refund will be made after signing up for the program(s). Each month has a make up class available.

7.   I have read and agree to the Conditions of Enrollment.

    The program(s) I would like to sign up for:

 Parent(s) Signature: ______________________________________________________________

 Today's Date: ____________________________________________________________________

Payment Method: (Registration fee: $ 50.00/pp)

 _____Check               _____Cash                  _____Credit Card                  _____Money Order

 If using a credit card, please fill out following information:

 Cardholder's Name: _________________________           Expiration Date: _______/____________

 Credit Card Number: /__/__/__/__/---/__/__/__/__/---/__/__/__/__/---/__/__/__/__/

         ____Visa        ____Master Card       ____Discover        ____American Express

            Signature                                                                                            Date