Apply to participate in an Extension Program

Thank you for your interest in the Extensions programs of NCMACC. In order to participate in any of these programs, we request that you complete the form below and return it to NCMACC with the required fees. Thank you for your interest in this program.

There are certain pieces of information that we must have at a minimum, the required items are marked with an asterisk, (*), and are also in red.

Student Information *First Name *Last Name

*Date of Birth

*Address 1:
Address 2:

*City: *State: *Zip Code:

Telephone (Please include area code) *Contact: Alternate:

Best Time to call: Morning Afternoon Evening Anytime

Class Asian Art European Art Tai Chi Taekwondo

Emergency Contacts Whom should we contact if you can't be reached?

Name

Relationship

Telephone:

FEES Registration Fee:  $40, one time, non-refundable fee per person.
Program Fee:  Asian Art, (10 weeks):  $265.00
                          European Art, (10 weeks):  $265.00
                          Tai Chi:  $80 permonth
                          Taekwondo:  $80 per month
Program fees for Tai Chi and Taekwondo are due at the first class of each month.

PHOTO CONSENT AND RELEASE
From time to time, Northern California Music & Art Culture Center, or its designated photographer, photographs the students during various activities, for use in NCMACC publicity materials. NCMACC will not list the names of any student without the expressed written consent of the parent for a specific purpose.
I, (parent/ guardian), do do not consent to this Photo Release allowing my child's photograph to be taken during class activities. I grant permission to NCMACC to use my child's image, either electronically, either individually or in group photos of students, for use in NCMACC pubility materials for general publicity, including, but not limited to, use in brochures, newsletters, flyers, press kits, press releases, and the NCMACC website.

I do hereby agree to the above stated statements and conditions.

Note: You must show your agreement by clicking on the check box above.