Application Form

Program Request (1) Date:

Program Request (2) Date:

Name:

Address:

City: State: Zip:

Phone: Ext: Fax: E-Mail:

Occupation:

Method of Payment

Check is enclosed payable in U.S. funds

Charge my:

Credit Card Number: Expiration Date:

Name as it appears on card:

Signature (required) ______________________________________________________________________

Deposits, Cancellations & Refunds

• Submit 50% tuition cost with application to reserve a place.
• Balance of tuition is due 30 days before program begins.
• If notice of cancellation is received over 30 days in advance of program, deposit will be
refunded, minus a $50 administration fee.
• If notice of cancellation is under 30 days, deposit is non-refundable.
• If Great River Arts cancels a program, your deposit will be refunded in full.

Please fill out this form, PRINT, and mail to:

Great River Arts
Box 48
Bellows Falls, VT 05101

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