Moco Arts - Transforming Lives Through Movement and Creative Expression

Summer CAKE
Summer CupCAKE
Vacation Camp
Teachers
Performances
Registration Form
Financial Assistance

REGISTRATION FORM
Click to Download & Print

Student’s Name __________________________________ D.O.B. ________________

(if under 18)
Parent / Guardian Name: _________________________________________________

Mailing Address: ________________________________________________________

City: ________________________________ State: _________ Zip: ___________

Phone: (H) ______________ Work: _______________ Cell: _______________

E-mail: ______________________________________________________

Emergency Contact
Name & Phone: ________________________________________________________

Class ______________________	Day / Time ______________________	Cost ______________________
Class ______________________	Day / Time ______________________	Cost ______________________
Class ______________________	Day / Time ______________________	Cost ______________________

PAYMENT OPTIONS (Check one)	PAYMENT (Check one)
___ Paid in Full	___ Cash
___ 2 Payments	___ Check
___ 4 Payments	___ Credit Card
$15.00 Processing fee for Payment Plans	___ MC ___ Visa
	_______/_______/_______/_______
DISCOUNT TYPE (Check one)	Exp. Date ____/____
___ Senior Citizen (65+)	Amount Paid $___________
___ Student	Amount Due $ ___________
___ I'm taking multiple classes
___ More than one family member attending classes

To register for programs, please fill out the registration form above. Mail completed form to: Moco Arts • 76 Railroad Street • Keene, NH 03431. Call 603.357.2100 with questions.