Creative Writing workshop Sign-UP

$250*
Make checks payable to MODERN ART or Contact Libby for digital payment
due by June 28th

* Financial assistance available: contact Libby at 610-761-9799 for more information.

Participant Name

First Name

Last Name

Participant Age

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

In Case of Emergency Contact

Does the student have any medical conditions, allergies, or dietary restrictions we should be aware of?

I am ok with photos of my child being taken and used for Modern Art.

Yes