Registration

Name: ________________________________________________________________

Child's Name and Age ____________________________________________________

Address: ______________________________________________________________

______________________________________________________________________

Phone (Day): ________________________ (Evening): __________________________

Email: _________________________________________________________________

Classes/Programs: _______________________________________________________

______________________________________________________________________

$________________ Total tuition

$________________ Basic Membership $50 (optional)

$ _______________ Total materials

$ _______________ TOTAL ENCLOSED

___ Check enclosed

___ Credit card

VIsa/MasterCard/AmEx # _____________________________________ Exp. Date.______

Signature _______________________________________________________________

Shelburne Art Center
PO Box 52
Shelburne VT 05482