Class Registration Form - This Century Art Gallery

This Century Art Gallery - Class Registration Form
Name:__________________________________________________________________
Address:________________________________________________________________ City:_______________________________________State:___________Zip:__________
Phone:_____________________________ Email:________________________________
TCAG Status Member:__________ New Member:__________ Renewal:__________ Single $35. ______ Family $50. ______ Student $10. (18 & Under) ______
Virginia Museum of Fine Arts Partner Membership Single $20. ______ Family $30. ______
Class Selection & Fees Class No. 1, Title:_____________________________ Fee: $_____________ Instructor:___________________________________ Time:______________

Class No. 2, Title:_____________________________ Fee: $_____________ Instructor:___________________________________ Time:______________

Class No. 3, Title:_____________________________ Fee: $_____________ Instructor:___________________________________ Time:______________

Payment Method: Cash Check No.#:______________ Credit Card: Visa Mastercard Name on Credit Card:_____________________________________________________ Credit Card Number:______________________________________________________ Exp. Date:______/_______ Signature:_______________________________________________________________
Total Amount Due: $_____________
This Century Art Gallery photographs classes for archives and publicity materials. Please sign to authorize permission to be photographed. Signature:_________________________________________________________

This Century Art Gallery - Class Registration Form