Etiqueta Excellence Manners

 Registration Form

Child’s First & Last Name : ___________________________________________

Home Address:____________________________________________________

Age______ Grade______Name of School________________________________

Sports/Activities____________________________________________________

Allergies?___Yes______No explain:

Parent’s First & Last Name: ___________________________________________

Phones:H_____________________Cel_________________Work____________________

Email: ___________________________________________

In case of emergency contact:

Name: __________________________

Relationship: ___________________

Phone: ________________

Person (s) authorized to pick up your child:

( ) Check if same as emergency contact

Name: __________________________

Relationship: ___________________

Phone: _______________

How did you hear about our program?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I authorize my child to be photographed in the classroom and his image used for the promotion of our programs on our website and other websites. Yes ( ) No ( )

Name:_________________________________Signature:_______________________________

Date:________________________________

*Parents & legal guardians assume responsibility for any harm that the child may cause others or to private property where class is held or of the other students.

Class Start Date:_____________________________

To reserve your space, payment must be received with registration.

www.etiquetaexcellencemanners.com

www.etiquetaexcellencemanners.blogspot.com

Broward: 954-655-8820 Palm Beach: 561-255-0549