REGISTRATION FORM, please print & fill out one form per student and
Mail to: Yocum Institute for Arts Education - 1100 Belmont Avenue - Wyomissing, PA 19610 - Attn. REGISTRAR
Student Information: Date of Registration: _________
Full Name___________________________________________________________________________________
Address____________________________________________________________________________________
City______________________________________________ State________ Zip________________________
Phone: Home _______________________ Work _______________________ Cell _____________________
Email___________________________________ ARE YOU A MEMBER? YES NO
Signature__________________________________________________________
If student is under 18: Date of Birth ___/___/___ Age at Time of Class_____ Current Grade_____
Parent Guardian Name_______________________________________________________________
Parent/Guardian Signature___________________________________________________________
Class Information:
1. Class #:_________ Class Name:_____________________________________Class Fee: $________
Day/Time of Class_________________________________________________________
Circle One: Fall - Mini Session - Winter - Spring - Summer - Ongoing/ Private - Workshop
2. Class #:__________ Class Name:_____________________________________Class Fee: $________
Day/Time of Class________________________________________________________
Circle One: Summer - Ongoing/ Private - Workshop
Total Class Fee: $________
Total Due: $________
Payment: Check # _______ or
(circle one) Visa, Mastercard # __________________________________ Exp. Date ____________
Authorized Signature for Credit Card:_________________________________________________
The Institute of the Arts reserves the right to change, withdraw or modify classes or workshops.
For office use: RB CS DS
CLICK HERE FOR SCHOLARSHIP APPLICATION