Manners at Mimi's Student Enrollment and Information Form
***Please confirm class space before enrolling, thank you.***
Please print and fill out this enrollment form.
Name of participant:____________________________________________
School attending:_____________________DOB____________Age:______
Please list any food allergies:___________________________________
Parent/s name:_______________________________________________
Address:____________________________________________________
Home phone:__________________ Cell phone:_____________________
E-mail:______________________________________________________
Emergency contact:___________________________________________
Cost: $28 per Class. Please make check payable to Polite Is Right.
Please bring this form and payment to Mimi's Cafe on the date you have enrolled in. Thank you!
I, __________________________, declare that I am the parent/legal guardian of ____________________________. I the undersigned do hereby agree to allow the individual(s) named herein to participate in the aforementioned activity(ies), and I further agree to indemnify and hold Denise Honaker and Polite Is Right and Mimi's Cafe, harmless from and against any and all liability for any injury which may be suffered by the aforementioned individual(s) arising out of or in any way connected with his/her/their participation in this activity.
Signature:_____________________________ Print Name:_______________________ Date_______
Sign below, if you will allow your child to be photographed or filmed for advertisement in, print and /or TV media for Polite Is Right.
Signature:_____________________________ Print Name:______________________ Date:_______
