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STUTZARTSPACE
STUDENT REGISTRATION FORM
Please complete and return
with full payment to:
Educational Services
STUTZARTSPACE
212 w. 10th Street, Ste. A-250
Indianapolis, IN 46202
Please complete a separate
form for each student
STUDENT INFORMATION:
Name:
_________________________________________________________________
Address:
_______________________________________________________________
City:
__________________________________ State: ____________ Zip: ___________
Home Phone:
_____________________ Work/Emergency Phone: __________________
E-mail (optional):
___________________________________________________
Birthdate (if under 18
years): ________ Parent/Guardian Name: ______________
CLASS INFORMATION:
Class:
________________________ Instructor:
____________________ Fee $_______
Class:
________________________ Instructor:
____________________ Fee $ _______
Class:
________________________ Instructor:
____________________ Fee $ _______
Subtotal $ _______
Donation $
_______
Total Enclosed $
_______
Method of Payment:
_____ Check (#_____) _____
Visa _____ MasterCard
Account #:
_____________________________________________
Expiration Date:
_________________________________________
Name on Card:
__________________________________________
Please print
Cardholder’s
Signature:
__________________________________________________
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