Are you registering yourself a child a friend other:

If registering a child:
What is your relationship to the child: mother father grandparent other:

What is your name: First Last

Age of child being registered:

Student's Contact Information:

Name: First Last

Phone Number:   Is this a home phone work phone cell phone

Alternate Phone Number:   Is this a home phone work phone cell phone

Email Address:

Mailing Address: Street: City: State: Zip:

What is the best way and time to reach you:

Lesson Information:

For what type of coaching are you registering?

Art:
Private Semi -private (available subject to enrollment of multiple students)
Basic Drawing Intermediate Drawing Design & Art Direction Story Boarding

Theater:
Private Semi -private (available subject to enrollment of multiple students)
Aspiring Actor Developing Actor Private Coaching

Music:
Beginning Piano

Creative Writing:
Private Semi -private (available subject to enrollment of multiple students)
Story Building

Where do you want your coaching? Instructor's home Student's home

What is your preferred time block for scheduling your lesson?
Monday 10 a.m - noon Monday 2 - 6 p.m.
Wednesday 10 a.m. - noon Wednesday 2- 6 p.m.
Saturday 10 a.m - 6 p.m.

If preferred time is not available, what other times are you availalbe (check all that apply):
Monday 10 a.m - noon Monday 2 - 6 p.m.
Wednesday 10 a.m. - noon Wednesday 2- 6 p.m.
Saturday 10 a.m - 6 p.m.

Where did you hear about Creativity Coach?
Received a flier in my mailbox
Saw a flier posted in a store/restaurant
Saw an ad in the Community Theatre of Howell program
Saw an ad in Livingston Parent Journal
Saw an ad in The Hartland Players program
Recieved an email
Word of mouth / referral (enter person who gave referral):

Additional notes, questions or information you wish to share:

Thank you for registering. Please click submit to register or refresh to clear this form and start over.