Registration Participant's Name* First Last Are you are parent or guardian of the person being registered?? Yes, I am their parent or guardian No, I am registering myself Parent / Guardian Name* First Last Additional Parent / Guardian Name (optional) First Last Relationship to Participant* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone*Home Phone (optional)Work Phone (optional)Email* ClassesClasses are offered Tuesday, Thursday, and Friday. We encourage choosing all 3 days for best selection. Classes are subject to change. Check all you wish to attend.Days Tuesday (Level Up, Book Club, Yoga) Thursday (Art, Life Skills, Zumba) Friday (Gym, Let's Talk, Cooking) Requested Start Date MM slash DD slash YYYY Please note: We require a 2-week waiting period before your first class.Emergency ContactPlease indicate another person to call in case of emergency.Emergency Contact Name* First Last Emergency Contact Phone*Do you currently take medication?* Yes No Please list your medications:Drug Sensitivities Allergies Dietary Restrictions Please list any other concerns we should be made aware of:ConsentThe parent or guardian must consent to the releases below. The photo release is optional..Medical Release* I agree.If the participant needs medical treatment while participating, 911 will be called. It is my wish that the treatment is started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physicians believe are needed, on the understanding that efforts to contact me will continue to be made. I accept responsibility for all costs related to such treatment.Outings Release* I understand.KALEIDOSCOPE OF WNY, INC. does not participate or plan community outings outside the parameters of our class time. While some may enjoy social functions together after classes, it is not part of Kaleidoscope of WNY, Inc.Photo Release* Yes No I authorize my participant’s picture to be taken and posted on social media and/or website.Registration FeeA non-reimbursable/non-refundable fee of $25 will be charged yearly for each participant.Registration Fee Price: I would like to pay* with a mailed check online Make check payable to Kaleidoscope of WNY, Inc. and mail to: Beverley Britzzalaro, Treasurer 5616 Strickler RoadClarence, NY 14031Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name CAPTCHACommentsThis field is for validation purposes and should be left unchanged.