Registration Please complete the following information * Required Field Student's Name * FIRST - LAST Workshop/Class Name * Workshop/Class Adult Community Workshop Kihon Taiko I (Beginning Class) Kihon Taiko II (Intermediate) Kitsune Taiko Youth I (ages 7+) Tora Taiko Youth II Usagi Taiko (ages 4-6) Parent-Child Workshop Issho Ni Youth Summer Camp Taiko Building Workshop Drop-In Taiko Session Fall Winter Spring Summer Workshop/Class Adult Community Workshop Kihon Taiko I (Beginning Class) Kihon Taiko II (Intermediate) Kitsune Taiko Youth I (ages 7+) Tora Taiko Youth II Usagi Taiko (ages 4-6) Parent-Child Workshop Issho Ni Youth Summer Camp Taiko Building Workshop Drop-In Taiko Session Fall Winter Spring Summer Workshop/Class Adult Community Workshop Kihon Taiko I (Beginning Class) Kihon Taiko II (Intermediate) Kitsune Taiko Youth I (ages 7+) Tora Taiko Youth II Usagi Taiko (ages 4-6) Parent-Child Workshop Issho Ni Youth Summer Camp Taiko Building Workshop Drop-In Taiko Session Fall Winter Spring Summer Student Status Returning Student New Student Date of Birth * Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 Parent/Guardian's Name (MINORS ONLY) Phone * Alt Phone E-Mail * Address * City-State-Zip * Emergency Contact * Emergency Phone * Alt Phone Please list any allergies Please list any special needs Additional Comments Payment Options Full Tuition $ Deposit Class space may be reserved with a non-refundable deposit of $50. Tuition balance is due two weeks before the start date of class. Balance Due: $ Payment Method Online (credit service fees may apply) Your Bank's Online Bill Pay Service Check by Mail: Portland Taiko 3230 NE Columbia Blvd. Portland, OR 97211-2032 Refund Policy Class registration withdrawal requests that are received two weeks prior to the start date of the class are eligible for a full refund minus a $50 processing fee. Requests received after that time will be credited to your next class registration. Workshop refund requests are only eligible for credit. Credit expires one year from date of issue. All refunds and credits are subject to Portland Taiko approval. Photo Release YES, Portland Taiko may use photos & video of me and/or my child for promotional purposes. Liability Release * I authorize the directors, employees, teachers, and assigns of Portland Taiko to secure proper treatment for myself or my child in a medical emergency. I release and discharge Portland Taiko from any and all claims for personal injuries. I am (or my child is) physically fit to practice and engage in the intensive physical program normally connected with Taiko training and there is no reason known to me/my child for not participating in these activities. I agree that Portland Taiko has permission to contact me in the future at the above mailing address, phone number and e-mail address. This agreement shall remain in effect until I have actively ceased any activity with Portland Taiko and have also given 30 days written notification of intent of being released from this wavier. * Initial Here Please confirm you registration by re-typing your name * * BEFORE SUBMITTING PLEASE PRINT THIS PAGE FOR YOUR RECORDS
