Step
1
of
5
20%
Your Personal Information
Your Name
(Required)
First
Last
Gender
(Required)
Male
Female
Prefer not to say
Other
Languages Spoken at Home
(Required)
Farsi
English
Other
Date of birth
(Required)
MM slash DD slash YYYY
Grade
(Required)
Prior Experience (if any)
Yes
No
Your Email Address
Your Phone
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Personal Information Parent 1
Your Name (if you are 18 or older, please enter your own information.)
First
Last
Your Email Address
Your Phone
Personal Information Parent 2
Your Name
First
Last
Your Email Address
Your Phone
Medical & Emergency Info
Allergies or Medical Conditions ( Required if applicable)
Yes
No
Doctor’s Name & Phone (optional)
Authorization for Emergency Medical Treatment
(Required)
I authorize Peykan staff to seek emergency medical treatment if necessary.
Photo/Video Release
Do you consent to allow Peykan to use class photos/videos for marketing purposes?
(Required)
Yes
No
Payment & Policy Agreement
Classes (per month)
(Required)
The class duration: One Hour
Farsi Class $160.00/month
Painting Class under 12 years old $120.00/month
Painting Class 13 years old and up $140.00/month
Acting Class(adults): $400.00/month
Acting Class(Teens): $300/month
Acting Class(Kids): $250/month
Precessing Fee
Price:
$0.00
Total
Credit Card
(Required)
Cardholder Name
Card Details
Refund and Cancellation Policy Acknowledgment
(Required)
I acknowledge I have read and understood Peykan’s refund and cancellation policy.
Privacy Policy
Liability Waiver & Consent to Participate
(Required)
I release Peykan from liability except as provided by California law and consent to participation in classes.
Full Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
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