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 Country

Cell Phone*

Home Phone (optional)

Work Phone (optional)

Email*

Classes

Classes 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

Please note: We require a 2-week waiting period before your first class.

Emergency Contact

Please 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:

Consent

The 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 Fee

A 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 Road
Clarence, NY 14031

Payment Method

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Emergency Contact

Consent

Registration Fee

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