Parent/Gaurdian:________________________________________________ Name of Student:_________________________________________________ Address: ______________________________________________________ City:________________________________ State:_____ Zip:____________ E-mail: _____________________________________________________ Phone (home):______________________ (work):_____________________ Emergency Contact (name): _____________________ (phone):_____________ Programs (names & dates): _____________________________________ ____________________________________________________________ Special Interests / needs / allegergies: _________________________________ ____________________________________________________________ Would you like to donate a tax deductable contribution towards student scholarship funds? Amount of Contribution: ___________________________________________ ArtSplot T-Shirt $15.00 (Circle One) Colors: Heather Grey / Natural Sizes: Small Medium Large ArtSplot Berets $15.00 (Circle One) Colors: Black / Red Sizes: One Size Fits All Amt:______ Form of Payment: Check / Credit Card Credit Card #: ______________________________________ exp: ________ **We are now accepting credit card payment** **Payment on your credit card statement will be under ACES** Mail to the ArtSplot: Suite 212 111 S. Grand Ave. Bozeman, MT 59715 All payments are non-refundable unless prior arrangements are made. Notes: Your e-mail address will help us to keep you current on ArtSplot/ACES offerings. |