PAVAN - Performing and Visual Arts Northwest

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September 07, 2010

Arts Alive Application

If you have any questions, please contact Shirley Dunsmore at 540-665-1294.

Please enter the following information.

Applicants First Name:

Last Name:

Middle Initial:

Street Address/Box Number:

Town/City:

State:

Zip Code:

Parent/Guardian’s First and Last Name:

Home Phone Number (with area code):

Work Number(s) Including Extension:

Parent’s Cell Phone:

E-mail Address:

Secondary Emergency Contact First and Last Name:

Work Phone:

Cell Phone:

Applicant's E-mail Address

Applicant’s E-mail Address (required) You will receive confirmation of PAVAN receiving your application via e-mail only.

My Residence is in:

Age:

Date of Birth:

DD/MM/YYYY

Current Grade (Seniors can not apply.)

The school I am presently attending:

My school is:

	Public
	Private
	Home-Schooled

Parent/Guardian Statement

My child, , has my permission to participate in the 2009 Arts Alive Day Camp at the site indicated at the top of this page. I understand that my child’s application must be complete in order to be considered for admission. I understand that shortly after I receive an e-mail confirmation from the PAVAN office stating it has received my child’s application and payment, my child and I will receive a handbook and medical forms which I will read, sign and return to the PAVAN office.

Click if you accept this agreement.

I accept these terms

Tuition will be announced as workshops become available.
• Return both pages to the PAVAN office: 203 S. Cameron St., Winchester, VA 22601, attention: The PAVAN Office. You may also fax the application to 540-665-4598.
• The deadline for all Arts Alive applications will be announced as workshops become available.

Thank you.

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