Online Registration Form

First Name:
Last Name:
Membership Status:
Gender:
Grade:
Year of Birth
Contact Person First Name:
Contact Person Last Name:
Street Address:
City:
State:
ZIP:
Phone:
Emergency Phone Numer:
E-mail Address
Class Name:
I authorize the Burlington Art Center to photograph, film and/or record vocally my child. These records may be used for promotional or publicity purposes and may be published in mass media publications or on our internet site. The child(ren)'s and family names may be used. This release is effective until revoked in writing. Such revocation shall only be effective to prevent an expanded future use of the records