Madison Youth Strings Enrollment Form

The Richmond Area Arts Council will offer two violin classes for students in first through fifth grades on Wednesday evenings at the Arts Center, 399 W. Water Street, beginning January 4.

Tuition for Spring semester - $75
Instructor:  Brenda Stratman
 

Fill out the form below to reserve a spot for your child.  This is a mandatory step for enrollment.
Tuition is due by January 15, 2012.

Name of Youth: *

Age: *

Grade: *

Birthdate: *

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Street: *

City: *

Zip: *

Home Phone:

Cell Phone:

Mother/Guardian: *

Mother's Home Phone:

Mother's Cell Phone:

Mother's Work Phone:

Father/Guardian: *

Father's Home Phone:

Father's Cell Phone:

Father's Work Phone:

INFORMATION REQUIRED IN CASE OF AN EMERGENCY

Emergency Contact: *

Emergency Contact Home Phone: *

Emergency Contact Cell Phone: *

Emergency Medical Consent for Treatment of Minors: *

In the event of a medical emergency related to the minor child listed above, I hereby request Pattie A. Clay Hospital to contact me at the telephone number(s) listed below. In the event I, or my spouse, are unavailable, I hereby give my written consent to Pattie A. Clay Hospital, or any other hospital, to render whatever emergency medical care may be deemed appropriate by the hospital's emergency medical staff, until I or my spouse may be contacted. The following providers are not employees of the hospitals, but are instead independently contracted to provide services for the patient, and are legally responsible for their actions: All physicians, including E.R. physicians, pathologists, technical and professional components, radiologists, anesthesiologist, and therapists.

Medication Allergies:

Seasonal Allergies:

Food Allergies:

Medications being taken:

Date of Last Tetanus Shot: *

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Date of Last immunizations: *

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Year1997199819992000200120022003200420052006200720082009201020112012

List Any Special Medical Conditions:

Parent/Legal Guardian: *

Relationship: *

(note: only parents or legal guardians can authorize emergency medical treatment)

Email Address: *

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