REGISTRATION FORM

Date:__________

_________________________________________________ _______ ____/____/____
Name                                              Senior?     Youth?
                                                   (65+) (DOB Mo/Day/Yr)

________________________________________________________________________
Address

_______________________________________________ _______ ________________
City                                            State   Zip

(____)_________________________ (____)__________________________
Home Phone                      Business Phone	
........................................................................
___ Pay by Check
___ Pay by Credit Card:               Master Card:___ Visa: ___

_________________-_________________-_________________-__________________
Credit Card Number

_______________________________ _______/_______	________________________
Signature                       Expiration Date V-code (3 digits)	
........................................................................
COURSE CHOICES:

1._____________ _______________ _______________________________ ________
  Course ID     Day & Time      Course Name                     Tuition

2._____________ _______________ _______________________________ ________
  Course ID     Day & Time      Course Name                     Tuition

3._____________ _______________ _______________________________ ________
  Course ID     Day & Time      Course Name                     Tuition

                                            Total Tuition Cost: ________

                                 Senior Citizen Discount (10%): ________

                                   *REQUIRED Annual Membership: ________
                                                  
                                               **Material Fees: ________

                                                      Donation: ________

                                                 Total Payment: ________

* Annual membership is $20 for youths, $40 for adults (15 & up enrolled in adult 
classes), $50 for families, and $10 for an upgrade from adult to family
membership. The non-refundable membership fee helps keep the cost of tuition 
down and is not pro-rated.

** See course listings for material fees.

Please help us to keep costs down by paying with your personal check made out to
"the Art School at Old Church".

Submission of registration denotes acceptance of refund policy (see online). The 
Art School at Old Church appreciates the use of photos taken by staff, faculty
and members to illustrate our catalogs. Please notify us in writing if you do
not wish to have your photograph published.