KIDS-ON-CAMERA REGISTRATION
BE SURE TO READ KIDS-ON-CAMERA POLICIES FIRST.
To register fill out form completely, PRINT and
fax to 510-232-1237 or call us at 415-440-4400.
Click here to go back to KIDS-ON-CAMERA's Welcome page.
 
STUDENT(S) INFORMATION
1st Student M F DOB Age
1st Course # & Date 2nd Course # & Date
2nd Student M F DOB Age
1st Course # & Date 2nd Course # & Date
 
PARENTS INFORMATION
Name Address
City State Zip
Day Phone Eve Phone
Fax
Pager/Cell Who's
E-Mail Who's
 
JUST FOR OUR INFORMATION
Where did you hear about us?
What's your primary purpose for attending Kids-On-Camera?Personal Development
TV Commercials/Modeling Both Other
Does your child have an agent? Yes No.
Agent's Name
 
VIDEO & PHOTO RELEASE UNDERSTANDING
I hereby irrevocably consent to and authorize the use and reproduction by KIDS-ON-CAMERA, of and and all photos or videos which have been taken of my child(ren) in class, for promotional purpose of our school (such as our Newsletter, this web site, etc) without compensation to me. I agree that videos or photos are the sole and complete property of KIDS-ON-CAMERA.
SIGNATURE: Sign here after you printed this form.
   
EMERGENCY INFORMATION (other than parent)
In case parent can't be reached.
Name Home Phone
Cell Phone Work Phone
Who other than child's parents is authorized pick up your child?
Name Phone
Indicate what action you want our personnel to take if injury or illness is of serious nature:
1. In the event you can't be reached do you give permission for KOC authorities to obtain medical aids or ambulance services at your own expense? Yes No
2. If NO, what do you want KOC authorities to do?
3. Physician name & phone required
Physician Phone
 
PAYMENT INFORMATION

SPRING 8-WEEK SERIES
 - Minimum Deposite: $125 per 8-week series & per student.
- $10 pre-payment discount applies if paid in full by 2/15/12
- $10 sibling discount (2nd student from same family)

 $
ONE-DAY WEEKEND WORKSHOPS IN SF
- Full pre-payment required
- Pay plans available for multiple workshop, no sibling discounts. 		$
TOTAL AMOUNT ENCLOSED $
 
PAYMENT METHOD
Check** (Check #) Money Order** Cash
Visa* Master* Discover*
Card No Exp. Date
I wish to charge $ to my credit card
*CHARGE SIGNATURE
Sign here after you printed this form. _________________________________________

**PRINT AND MAIL THIS FORM WITH ACCOMPANYING CHECK OR MONEY ORDER.
SPACE IS NOT RESERVED UNTIL PAYMENT IS RECEIVED.

I VERIFY THAT ALL INFORMATION ON THIS FORM IS CORRECT
Signature (Print and sign here)
 
Date (Print & write in date)
REGISTRATIONS WITH A CREDIT CARD:
Print form and fax to Kids-On-Camera at 510-232-1237
 REGISTRATIONS WITH A CHECK:
Print form and mail to
Kids On Camera, P.O. Box 70862, Pt. Richmond, CA 94807-0862
QUESTIONS? Call us at: 415-440-4400

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