Children Registering by chenmeixiu

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									                                                                 2011 Summer Registration
                                                                                     Session is from June 20th through August 20th
                                                                                    510-597-1619 | 1000 42nd Street, Oakland, CA 94608 | www.destinyarts.org

RETURNING FAMILIES: If your information has not changed please just complete the back of this form.

Under Health Information please list any problems, injuries, allergies or medicines taken that might affect your child(ren) from participating fully in the activities.


Child 1:                                                                                     Nickname:                              Date of Birth:

Gender:            School:                                              Home Zip Code:

(check all that apply)           African descent           Latino/a         European descent              Asian descent            Indigenous           Pacific
Islander        South East Asian              Semitic         Additional description:

Health Information:




Child 2:                                                                                     Nickname:                              Date of Birth:

Gender:            School:                                              Home Zip Code:

(check all that apply)           African descent           Latino/a         European descent              Asian descent            Indigenous           Pacific
Islander        South East Asian              Semitic         Additional description:

Health Information:




Child 3:                                                                                     Nickname:                              Date of Birth:

Gender:            School:                                              Home Zip Code:

(check all that apply)           African descent           Latino/a         European descent              Asian descent            Indigenous           Pacific
Islander        South East Asian              Semitic         Additional description:

Health Information:




Child 4:                                                                                     Nickname:                              Date of Birth:

Gender:            School:                                              Home Zip Code:

(check all that apply)           African descent           Latino/a         European descent              Asian descent            Indigenous           Pacific
Islander        South East Asian              Semitic         Additional description:

Health Information:


PARENT/CAREGIVER INFORMATION

Parent/Caregiver (primary contact):                                                                                                Relation:

Cell #:                         Home/Work #:                                Email:

Occupation:                                                           Company:                                      Interested in Volunteering: YES - NO
Parent/Caregiver (secondary contact):                                                                                             Relation:


Cell #:                        Home/Work #:                                Email:

Occupation:                                                          Company:                                   Interested in Volunteering: YES - NO

ADDRESS & DEMOGRAPHIC INFORMATION

Home Address:                                                                                               City:                                Zip:


Mailing Address:                                                                                           City:                                Zip:


Annual Household Income                       Single Headed Household                 Dual Headed Household                Household Size:

        $0 - $30,000          $30,001 - $50,000                $50,001 - $80,000             $80,001 - $100,000                 $100,001 - or greater

                       CLASS REGISTRATION
                    (please check the classes child(ren) will attend)
                                                                                            Photo/Video Release
                                                                                            I agree that Destiny Arts Center may use photos or video

              ONGOING CLASSES (AGES 3-18)                                                   footage of the student(s) listed on this registration form for

          9-WEEK SESSION: JUNE 20                   TH
                                                         – AUGUST 20          TH            publicity both in print and on the web.
                                                                                            (cross out photo/video release if you disagree)

Child                                                                                                  Initial

1 2 3 4          MONDAY & WEDNESDAY                                     $144.00
                    5:00-6:30PM Modern Dance (AGES 13–18)                                   RELEASE
                                                                                            I understand that Destiny Arts Center programs are high impact
                    5:00-6:30PM Martial Arts – all levels (AGES 7–18)
                                                                                            and involve physical contact. Therefore I release Destiny Arts
                 TUESDAY & THURSDAY                                     $144.00
                                                                                            Center and its Instructors of legal responsibility for accidents or
                    5:00-6:30PM Hip Hop Dance (AGES 13–18)
                                                                                            injuries incurred while training in Destiny Arts Center programs
                 SATURDAY                                                $72.00             - on or off site.                                     Initial
                    10:00–11:00AM Hip Hop Dance (AGES 7–12)
                    10:00–11:00AM Teddy Bear Martial Arts – beginner (AGES 3–6)             See the IMPORTANT POLICIES document for details
                    11:00AM–12:00PM Teddy Bear Hip Hop Dance (AGES 3–6)                     on additional polices.
                    11:00AM–12:00PM Teddy Bear Martial Arts – intermediate (AGES 3–
                                                                                            By signing this document you agree to the terms and
6)
                                                                                            conditions of all our policies.
                    11:00AM–12:00PM Martial Arts – all levels (AGES 7–18)



                  CAMP DESTINY (AGES 7-12)
          FIVE ONE-WEEK SESSIONS, 9:00AM – 5:00 PM
     please also indicate if you require pre-care (8am-9am) or after-care (5pm-6pm)



                                                                          PC/AC

                    Week #1: Monday, July 11th – Friday, July 15th
                    Week #2: Monday, July 18th – Friday, July 22nd
                    Week #3: Monday, July 25th – Friday, July 29th
                    Week #4: Monday, August 1st – Friday, August 5th
                    Week #5: Monday, August 8th – Friday, August 12th
                                                           Uniforms & Merchandise
                                       FEES
                                                           $12 Destiny T-Shirt       # needed:       Total:
Ongoing Classes (9-week session):
                                                           $20 Martial Arts gi       # needed:       Total:
Weekday Classes (two classes/week):
                                                           $25 Destiny Sweatshirt    # needed:       Total:
$144.00
Saturday Classes (one class/week):
$72.00                                                      These fees represent only 20% of our programs’
                                                            true cost, and Destiny never turns anyone away for
Camp DESTINY:                                               lack of funds. Please donate generously to support
$150.00 - $300.00, sliding scale, per week                  our work and your community!
Pre-Care: $25.00 per week
After-Care: $25.00 per week                                 Donate what you can:



Scholarships are available please pick up an application   TOTAL DUE:
at our office or download one from our website.            Payment Options:
                                                           Checks (to Destiny Arts Center), Cash, Visa or MasterCard
Program Fees
Total Fees for Classes:
$10 Registration Fee (new families only):




Signature:                                                                       Date:

								
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