The Classical Institute Registration

Form Instructions:

Please click the Submit button at the bottom of the Registration Form for immediate delivery to The Classical Institute office. Thank you.

Fields marked with an "*" are required items.

* Student Name:

Age (if under 18 years old):

* Address:

* Home Phone (719-xxx-xxxx):

* Work Phone (719-xxx-xxxx):

* Cell Phone (719-xxx-xxxx):

Parent/Guardian Name (if under 18 years old):

* Email:

Emergency Information

* Emergency Contact Name:

* Emergency Contact Phone (719-xxx-xxxx):

Emergency Contact Cell Phone (719-xxx-xxxx):

Consent for Medical Treatment & Permission to attend (if student is under 18 years old)

I, the undersigned, give consent for my child to participate in The Classical Institute, with all the staff deemed harmless for all claims or actions due to any personal injury which may result from my child's participation. In the event I cannot be reached if an emergency arises, I hereby give my permission to the physician selected in the necessary treatment for my child.

Physician's Name:

Physician's Phone:

Insurance Co:

Hospital of Choice:

List known allergies:

Is your child taking any medications? Please list:

Course Registration

Class One:

Fee:

Class Two:

Fee:

Class Three:

Fee:

Class Four:

Fee:

Total Class Fee:

Make all checks payable to: The Classical Institute, Attn: Scott Wilson, 975 Stout Rd., Colorado Springs, CO 80921

For questions contact: The Classical Institute, 719-488-6254, email: swilson@asd20.org

Checking this box takes the place of your signature.

I have read and agreed to the registration/cancellation policies on the policies form.

* Today's Date (00-00-2008):

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* To prevent automated submissions please type in this number: 621