Name_________________________________
Age_______ Male_____ Female____
Parent/Guardian_______________________
Address______________________________
City, State, Zip ________________
Phone (work)____ (home)______
Phone (cell)_____ e-mail_______

If you DO NOT wish parent/guardian name to be added to our Accessible Arts mailing list please check here __

List special needs related to visual impairment, mobility, developmental, mental or other disabilities (see note on previous page).
__________________________________________
__________________________________________

Week #1, July 11-15, 2005
_____ (# of children) x $250 = _________

Week #2, July 18-22, 2005
_____ (# of children) x $250 = ________
TOTAL ENCLOSED________
_____Enclosed is my letter requesting a scholarship
(no scholarships will be given after July 1st)

Please send this form and your check payable to
Accessible Arts, Inc., 1100 State Ave., Kansas City, KS 66102
Phone: 913/281-1133 ~ Fax: 913/281-1515