Enrollment

To enroll a student, please complete the form below and mail tuition check to:

Media Poetry Studio
240 Carlester Dr.
Los Gatos, CA 95032

Tuition is $489 if enrolling by June 1. If enrolling after June 1, tuition is $589.
Make check payable to CALIFORNIA POETS IN THE SCHOOLS.
Tuition due date is June 30.
If you are unable to pay by check, please contact us to make other arrangements.
In case of cancellation, refunds are given at camp director's discretion. Cost of classes attended will be deducted from refund total.
Please read our Parent/Provider contract. You can sign and send it with tuition or sign in person on the first day of camp.

Parent / Legal Guardian

First Name

Last Name

Email Address

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell or daytime phone

(###)

###

####

Home phone

(###)

###

####

How did you hear about us?

Facebook

Website

Flier

Word of mouth

Other: Please specify

Student 1

First Name

Last Name

Age

Allergies / Medical Conditions / Medications / Special Accommodations / Other Notes

Student 2

First Name

Last Name

Age

Allergies / Medical Conditions / Medications / Special Accommodations / Other Notes

Student 3

First Name

Last Name

Age

Allergies / Medical Conditions / Medications / Special Accommodations / Other Notes

Emergency Contact 1

First Name

Last Name

Relationship to student

Is this individual authorized to pick up student?

*Camp will not release students to individuals under the age of 18.

Yes. The camp may release student to this individual.

No. The camp may NOT release student to this individual.

Cell or daytime phone

(###)

###

####

Emergency Contact 2

First Name

Last Name

Relationship to student

Is this individual authorized to pick up student?

*Camp will not release students to individuals under the age of 18.

Yes. The camp may release student to this individual.

No. The camp may NOT release student to this individual.

Cell or daytime phone

(###)

###

####

Emergency Contact 3

First Name

Last Name

Relationship to student

Is this individual authorized to pick up student?

*Camp will not release students to individuals under the age of 18.

Yes. The camp may release student to this individual.

No. The camp may NOT release student to this individual.

Cell or daytime phone

(###)

###

####

Additional Release Information

Use this section to specify other individuals authorized to pick up student (include full name and relationship to student) or to indicate other dismissal arrangements (student drives own car, student takes public transit, etc.). *Camp will not release students to individuals under the age of 18.

Notes

Use this section to include anything you wish to add.