REGISTRATION FORM Class/Workshop/Session Name_______________ Cost $_________ Student's Name:______________________________ Address: __________________________________________ City: ___________________ State: _____ Zip: ___________ Home Phone: ________________ Work Phone: ____________ E-mail: _____________________ If student is a child: Parent/Guardian: _____________________________ Student's Birth Date: _______ Grade/Home Schooled_____________ Gender (M/F)____ Food allergies or special needs___________________ Class Size Is Limited! Please make checks payable to: Katherine Devine 4828 Lytham Drive  Roanoke, VA. 24018 Although every effort is made to provide a safe and secure environment for all students, by signing this form the student/parent releases Ms. Katherine Devine of any responsibility for accidents. Ms. Devine and Devine Designs may use photos and films of my child for promotional material. Student/Parent signature _________________ Date ___________ Thank You!