________________________________________________________________________
Registration Form
Child’s Name__________________________________________________DOB___________
Parent/Guardian Name__________________________________________________________________
Street Addressate/Zip_____________________________________________________
Home telephone______________________________Cell_____________________
Email__________________________________________________________________
Emergency Contact (if different from above)
Name__________________________________Phone___________________________
Known Allergies/Concerns________________________________________________
How did you hear about us? _____________________________________________________________________
Class or Camp Info
_____________________ _______________________________
Title of Class/ Camp Date(s) and Time of Class/Camp
(Multiple classes/camps please see below)
Cost $_________________
Payment options Cash _ Check _ Credit Card _ if paying by credit card, please fill out the following:
Visa MasterCard Discover
Credit Card Number_________________Exp Date __________
Verification Code ___________
Name as it appears on card _______________________________________________________________
Billing address (if different from above) _______________________________________________________________
Mail check and registration form to:
Chow Bella 1480 Moraga Road, Suite 166, Moraga, CA 94556 or Fax (925) 388-0589
Questions: (925) 878-9932 / elaine@chowbella.net
Waiver and Release
I represent that I am the parent or legal guardian of the above individual and here by consent to the individual using the Facility, participating in the activities and participating in other activities sponsored by Chow Bella. In consideration for participate in the Activities, and participate in the other activities, I agree, personally and on behalf of the individual, to be bound by the terms and conditions of this Release. I further agree to indemnify, hold harmless and defend Chow Bella and all other Released Parties from and against any loss, damage, liability and expense, including costs and attorneys’ fees, incurred by Chow Bella or the other Released Parties as a result of the above individual using the Facility, participating in the Activities or participating in any other activity involving Chow Bella.
Chow Bella reserves the right to use any photograph taken at the Facility, or in connection with any Activities or other activity involving Chow Bella, including but not limited to those taken during a program, a birthday party, a group event, or other Activity, to be used in Chow Bella promotional materials, brochures and web-site.
_____________________________ ___________________________ _______
Printed Name of Parent/Guardian Signature of Parent/Guardian Date
Class Information
Date(s) and Time of Class Cost
__________________ __________
__________________ __________
__________________ __________
__________________ __________
__________________ __________
__________________ __________
__________________ __________
TOTAL __________
