2017 Mobile Summer Camp Registration

School Name *

School address *

School address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Phone *

School Phone

(###)

###

####

Director's Name *

Director's Name

First Name

Last Name

School e-mail *

Pick a date *

Pick a date

YYYY

Choose a venue *

How many kids will participate? (Min of 12 kids) *

What time ? *

PAYMENT INFORMATION

Payment Type *

Credit Card # *

Expiration Month *

Expiration Year *

3-4 Digit code on back of card *

What zip code does this card belong to?

Release of Liability/ Photo Release *

I grant Jimmy Potters Studio & Workshop, the right to take photographs of my child and his/her work in connection with any Jimmy Potters Workshop class.I authorize Jimmy Potters, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Jimmy Potters Workshop may use such photographs of my child with or without their name and for any unlawful purpose, including for example such purposes as publicity, illustration, advertising and web content

I've read the above and agree

Comments:

Choose a workshop *

Handprints

Pottery Painting

Clay Sculpting

All of the above