Art in Focus – Registration Form

Name of Student _________________________________________________________________________

Age ___________ (must be at least 7yrs.) Grade ________________________________________________

Diagnosis ______________________________________________________________________________

Any Allergies (“0”, if none)_________________________________________________________________

Address ________________________________________________________________________________

City/State ______________________________________________________________________________

Phone (H) __________________ (Cell)_________________ (Emergency) __________________________

E-mail Address _________________________________________________________________________

Personal artistic interests __________________________________________________________________

Sessions will be held only on the first Saturday in New Bern and the second Saturday in Bayboro of each month from 10:00 a.m. to 12 noon at Focus Therapy Services, Inc., unless indicated otherwise. Please arrive early to ensure that the project instruction can begin promptly at 10:00 a.m.

Class size may be limited. Please register early.

I give permission for my child to attend the “Art in Focus” workshop. I am aware that there will be a small cost per session of $8 for each student attending who is or was a client of Focus Therapy Services, Inc. to help cover materials for the workshop. This class is also available to the public at a cost of $20 per session for all disabled children. If the student cannot attend please notify Focus Therapy Services, Inc. 48 hours in advance. Without prior notice the fees are nonrefundable. Donations of funding and/or art materials are gladly accepted.

I hereby release Focus Therapy Services, Inc., and the Art in Focus facilitators from any and all liability connected with my child’s participation in the therapeutic art activities. I acknowledge that my child is participating in these activities of their own free will and I assume all risk in connection thereto.

Name of Student: __________________________________________________

Name of Parent/Guardian ____________________________________________

Signature _______________________________Date ______________________

Checks can be made payable to the Focus Therapy Services, Inc., and mailed to

PO Box 12192, New Bern, NC 28561