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PLC:

a006py

Agency:

city of clifton

For:

adult class registration

Phone:

973-472-5499

Address:

900 clifton avenue
clifton, new jersey 07013

*Required Field

Payment Information

*Registrant Name:

Middle:

*Last:

*Age:

*Emergency Contact Name:

Middle:

*Last:

*Emergency Contact Phone Number:

(### - ### - ####)

*Emergency Contact Email Address:

*Class Registration Type:

I, the above Registrant, has permission to take part in all activities at the Clifton Arts Center Class. This class takes place at the Clifton Arts Center building.

I hereby release the City of Clifton, its employees, agents and representatives associated with the class program from any and all claims or actions in connection of the operation and supervision of the art class.

*I certify I am not in need of any medications during the class and any pre-existing medical conditions of concern for the Clifton Arts Center staff are listed below.:

None

If has a condition, please use the Allergy/Medical Information Box to describe.

*I understand that the Clifton Arts Center does not have any medical professionals on site. Staff members will not administer medications and cannot monitor medical conditions.:

Yes

*In the event of a medical emergency, the Clifton Arts Center staff will seek outside medical assistance and contact the parent or guardian immediately. I authorize transportation to hospital and authorize emergency medical treatment.:

Yes

*I authorize that photos or videos maybe taken of me and artwork, which may be published and used to promote the Clifton Arts Center. Including use on our website and social media platforms.:

Yes

*I release the Clifton Art Center from any liability resulting from the use of the pictures.:

Yes

*For refunds, 5 business days before the event date are needed, plus a $5 fee to undo the reservations/ tickets so that a refund can be received.:

I understand

*The person requesting the refund has to send an email to: rcammilleri@cliftonnj.org and then call to confirm at 973-472-5499. When requesting the refund, please specify the purpose of the cancellation.:

I understand.

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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