Star Potential Studios – REGISTRATION FORM
Year: 2007/2008

Summer Session or Full Year  (circle one or both)

Student Information:

Last Name:____________ First Name:_____________
Sex (circle one) Male Female
Health Card #______________ Doctor’s Name ____________________
Doctor’s Phone #________________ ________
Allergies (circle one) Yes No If Yes:____________________
Disability (circle one) Yes No If Yes:____________________
Medication (circle one) Yes No If Yes: ___________________

Student’s Home Phone Number:_________________________
Home Address:___________________________ Apt #_______ City:______________________
Postal Code_____________________ Email Address _________________________________________________

Family Information:

Mother’s Last Name:_____________Mother’s First Name:_____________
Home Phone:___________________Work Phone:___________________
Home Address: ______________________________________________ Apt#_________________
City:______________________ Postal Code_____________________

Father’s Last Name: _____________Father’s First Name:___________
Home Address:____________________________ Apt#________________
City:______________________ Postal Code_____________________
Home Phone:_______________________ Work Phone _______________

Program Details For Student: 

            Name of Class         Day of Program        Class Time 
   1.       ____________________________________________
   2.       ____________________________________________
   3.       ____________________________________________


Emergency Contacts
1. Last Name:______________________ First Name:________________
Reachable Number:_________________ Relation:__________________
2. Last Name: _____________________ First Name:________________
Reachable Number:_________________ Relation:__________________

Method of Payment:

Cheque (circle one):Yes No Cheques Payable To: STAR POTENTIAL STUDIOS
Cash (circle one): Yes No
Visa  Yes No     Credit card#_____________________________expiry___________

Total: ________________________

Registration and payment must be returned to Star Potential Studios, BEFORE the start of classes.