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Academy of Fine Arts R E G I S T R A T I O N 2 0 0 9 - 2010 Date________________
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Student’s first name Last name
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Mother’s name Father’s name Home phone
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Street address City State Zip
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Mother’s work phone Cell phone E-mail address
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Father’s work phone Cell phone E-mail addrss
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Emergency contact name Relationship Phone
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Student’s grade in fall Age Sex Birthday School
How did you learn about the Academy? ____________________________________________________________________________________
Class(es) enrolling in:
1. ______________________________________________________________________________________________________________
Instrument/Class Teacher Day Start & End Times
2. ______________________________________________________________________________________________________________
Instrument/Class Teacher Day Start & End Times
_________ I have read, understand, and agree to the Registration information and Policies of the AFA.
_________ AFA may use my child’s picture for promotional purposes (please check).
Make check payable to Academy of Fine Arts and mail to
4519 Providence Road, Charlotte, NC 28226. Please use a separate form for each student.