Instructions:  Print from your browser, fill out and mail, fax  or bring to: Rogue Gallery & Art Center, 40 S. Bartlett St., Medford, OR  97501

Registration Form

Classes, Camps & Workshops

Rogue Gallery & Art Center                               FAX (541) 772-0294

40 South Bartlett Street                                             (541) 772-8118

Medford, OR  97501                                       www.roguegallery.org

One registration form per class.

Note: Emergency Release information must be filled out for complete registration of children.

Student Name:                                                                         

Parent Name:                                                                           (if under 18)

Street Address:                                                                        

City                                                      Zip                              

Home Phone                                         Cell                             

Class Title                                                                                

Dates of class                                                     Tuition _  ____

Are you a member?                   YES      NO

Add membership?  ($30 individual/$45 family)                         

I would like to donate to the Art Education Scholarship Fund

to help those who would not otherwise be able to attend.               __

    Grand Total                       

Payment Type

• Check (Made out to Rogue Gallery & Art Center)
• Visa/MasterCard/American Express

Billing address & zip code for card if different from above:

Number on card:                                                                 Exp. Date             

Signature:                                                                                

Amount to be charged:    $                                                         

Full payment is due at time of registration, unless applying for scholarship assistance. Email  Education Director for a scholarship application or additional information.