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September 07, 2010

Fall Classes Application

Please call or email Shirley Dunsmore at sdunsmor@su.edu or 540-665-1294 for a registration form for the Clay Sculpture class for the fall of 2009

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:

The school I am presently attending:

My school is:

	Public
	Private
	Home-Schooled

Please indicate your FIRST choice.

Parent/Guardian Statement

My child, has my permission to participate in the class(s) indicated above and I understand that I will be contacted at the phone number provided above in case of an emergency.

Click if you accept this agreement.

I accept these terms

Checks should be made payable to PAVAN/LCPS. Cash is also accepted. Please include your check or cash with this application. (Be sure to include separate checks for each class registered.) Thank you.

Applications will be accepted until all spots are filled!
Please return this application along with payment (separate checks for each class registered) to:
Performing and Visual Arts, Northwest (PAVAN), 203 South Cameron Street, Winchester, Virginia 22601
Attention: The PAVAN Office

Thank you.

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