Merrick Art Gallery

1100 Fifth Avenue
New Brighton, PA 15066
ph: 724-846-1130
director@merrickartgallery.org

Class Registration

*First Name of Student:

*Last Name of Student:

Address Line 1:

Address Line 2:

City:

State/Province:

ZIP/Postal Code:

*Class(es) enrolling for:

Please indicate week 1, week 2, both or date of class.

*Age of Child:

*Email:

*Phone:

Notes:
Please notify if someone other than named above is picking up the child.
List additional Children if necessary.

*Name of Parent or Guardian:
(If applicable)

Please list Parent(s) or Guardian(s), Age of Child and person paying for class if last name is different than the child.

Submit Registration:

1100 Fifth Avenue
New Brighton, PA 15066
ph: 724-846-1130
director@merrickartgallery.org