The Etiquette School of The Park Cities Enrollment Form
(Please scroll down to ensure you print and mail in entirety)
Student's Name:
_______________________________________ Male or Female
(last, first, M.I.)
Student's Grade:______ Age:______
Parent's Name(s):
_____________________________________________
_____________________________________________
Parent's Phone(s):______________________________
Parent's e-mail address:__________________________________________________________
Emergency Contact:
_______________________________________
Phone:_______________________________________
Physician's Name:
_______________________________________
Phone:_______________________________________
If your child has a food allergy, medication allergy, or medical condition please list it here:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Consent/Disclaimer:
I acknowledge that I am the parent/legal guardian for the above applicant. I hereby give my consent for emergency medical care prescribed by a licensed phsician and/or licensed paramedic. This care may be given under any condition necessary to preserve the well being or life of my child. I hereby release, discharge and otherwise indemnify Park Cities Etiquette, The Etiquette School of Frisco, all of it's employees and associated personnel, against any claim by or on behalf of the registrant as a result of the registrant's participation in The Etiquette School of Frisco or Park Cities Etiquette program.
Parent Signature:
_________________________________________________
Date:___________________________________________
Deposit Agreement:
I understand that there is a $100 non-refundable deposit per class. The deposit is applied to my tuition and is required to hold my place. If I am unable to attend my regularly scheduled class, I may apply the deposit to the next available class of my choice. My place will be held once my deposit and enrollment form are received.
Parent Initials:___________
Chosen Class Date(s) and name of class attending:
____________________________________________________________________________________________________________________________________________
Please mail your Enrollment Form(s) and checks (if not paying via Pay Pal) to:
Marsha Horne
PO Box 168
Seneca Falls, NY 13148
