2017 Mobile SC Registration

School information

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 *

What time ? *

Choose your workshop

Choose who will participate *

For Pre K & School agers, choose only one workshop (clay or pottery painting)

Toddler - Elephant Handprints

Pre-K Pottery Painting tape workshop

Pre K Clay workshop

School agers Pottery Painting Tape workshop

School agers Clay workshop

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

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