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Studio Artemis

Sculpture - Ceramics - Pottery Wheels - Tuition - Art Therapy

Enrolment Form Adult 2021

Class: ……………………….           Day/Time: …………………………

Name:…………………………………………………………………………………….

Age Bracket 18-25 26-35 36-45 46-55 56-65 66+ (please circle)

Asthma / Allergies to Nuts/Dogs or Other? (circle) no yes epi pen

Further Details ...................................................................................... .

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Home Address……………………………………………………………………………

……………………………………………………………..Postcode…………………

Tel: Mobile…………………………

Work/Home………….....................................

Email………………………………………………………

Emergency Contact Name……………………………

Tel…………………………

Other……………………………………………………………………………………….

How did you hear about us? ……………………………………………………………

What are the areas you would like to explore during this course?

………..………….…………………………………………………………………………

I wish to pay by: Cash Credit Card Visa MasterCard Direct Deposit

Amount: $..................... Paid in Full by Cash Direct Deposit

Credit Card Gift Voucher

Card Number .... …. …. …./…. …. …. …./…. …. …. …./…. …. …. ….

Expiry Date …. …./…. …. Cardholders Name………………………….

Cardholders Signature………………………...................Date………….

Office Use Only:

Receipt Number……………………………. Date…………………………….

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