Registration Form
Fall 2017 Ceramics Visiting Artist Workshops
Class or Workshop Catalog Number
Please enter the corresponding catalog number that appears on the page above.
Class or Workshop Title
Choose only one. Please register only one workshop per person per registration form.
Last Name
Your answer
First Name
Your answer
Date of Workshop or Event
EX: 10.31.16
Your answer
Email
Your answer
Phone
Please enter as such: 740.592.4981
Your answer
Street Address
Your answer
City
Your answer
Zip Code
Your answer
Are you a Dairy Barn Member?
Required
Are you over 18?
Required
Payment Options
Please let us know how you want to submit payment
For participants under the age of 18: I (name below) as the participant's legal guardian give permission for my child to participate in this Dairy Barn workshop or class and corresponding activities. In case of accident or serious illness, I request that I/we be contacted. I give permission for emergency medical treatment and to be transferred to the nearest medical facility. I agree to assume all costs related to such treatment and I release the Dairy Barn from any responsibility for injury or illness that may occur while my child participates. I understand that typing my name below constitutes my legal signature.
Your answer
Parent/Guardian Phone
Your answer
Once you have completed this form, click the big friendly yellow button to pay in the online gallery shop. Please email lyn@dairybarn.org and let Lyn know you have submitted the registration, in order to make certain it is received.
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