BASS ARTS STUDIO REGISTRATION FORM

Please fill out ALL FIELDS, print form, sign and mail to the address below with payment.

Student Name:__________________________________________________
Date of Birth (MM/DD/YY):____________Grade in School:_______________
Parent/Guardian Name:__________________________________________
Address:_______________________________________________________
City: ______________________________ Stte: ____________Zip:________
Email address:__________________________________________________
Phone numbers: Home: __________________Work or Cell: _____________
Contact (in case of emergency):__________________ Phone:_______________
COURSE TITLE /DAY/TIME_______________________________________
SESSION(S) - FEE: (add $15 reg. fee for new students______________________

Photo Release:
Bass Arts Studio DOES/DOES NOT (please circle one) have my permission to use photos of my child
for publicity.

I/ we the parents of the above named child do hereby give my/our approval to participation in any
and all of the activities. I/We do assume all risks andhazards incidental to the conduct of the activities
and transportation to and from activities; and do further hereby release, absolve, indemnify and hold
harmless Bass Arts Studio and the organizers and supervisors, any or all of them. In case of injury to
my/our child, I/we hereby waive all claims against theorganizers, the sponsors or any supervisors
appointed by them.

PARENT SIGNATURE_______________________ DATE ________________

Mail Registration Form with payment to Bass Arts Studio 202 Park Street. Montclair, NJ 07042
Make checks payable to Fern Bass. For information please call (973) 509-7588.