Class Registration 2021 Summer Fun Minerva Summer 2021 Registration Please register for one or both of our summer workshops below. Please fill out one form for each student if registering multiple students. For any questions, please contact Cassi at 413-884-0050 or info@minervaartscenter.org. Student InformationStudent Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Please enter a value between 0 and 99.Name of Parent or Guardian* First Last Email* Phone*Secondary Email (optional) Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency InformationEmergency Contact Name* First Last Emergency Contact Phone #*Alternate Emergency Contact Name AND NumberAllergies or Other Medical Conditions?*YesNoDetails*Do you wish to provide more information that may be helpful in an Emergency*YesNoStudent's Primary PhysicianPreferred Hospital for Emergency treatment if necessary?SchedulingKnown or Possible Schedule ConflictsMinerva summer 2021 WorkshopsPlease select your summer workshops belowCheck OutSummer WorkshopsPlease choose which workshop(s) you wish to register for Gleekers! (7/6-7/10) Little 2 Big (7/12-8/7) Total $0.00 I want to pay workshop tuition...*... now with PayPal... later with a check (Checks payable to Minerva Arts Center.)...pay by invoice or payment planPhoneThis field is for validation purposes and should be left unchanged. Please check back for updates, and subscribe to our newsletter to receive updates. Email address: Leave this field empty if you're human:
