Registration Information

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Name of Parent/Guardian: *
Name of Student: *
Age of Student: *
Current school attending and grade: *
Address: *
City: *
State: *
Zip: *
E-mail: *

Don't worry, we don't share this.
Phone (home): *
Phone (cell): *
Programs (names & dates): *
Special interests/needs/allergies/IEP: *
Emergency contact: *
Emergency contact phone: *
Would you like to donate a tax deductible contribution towards scholarship funds? *

Yes
No
Amount of Contribution:
Form of Payment: *

Check
Credit card

Payment on your credit card statement will read ACES!
Credit card:

VISA
MasterCard
Credit card number:
Expiration date:
Security Code: *
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All payments are non-refundable unless prior arrangements are made.

Payment on your credit card statement will read ACES!

Note: your e-mail address will help us to keep you current on ArtSplot/ACES offerings.

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