Recreation Application

RE-CREATION STUDIO
APPLICATION FORM

Please note: All applicants to this program must be adult consumers of mental health services.

Please Complete then Click on Submit Button:

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Program:

Class Name:

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Starting Date:

Ending Date:

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Student's Name:

Birth Date:

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Street Address:

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City:

State:

Zipcode:

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Residence Phone:

Email Address:

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Referring Contact:

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Agency::

Street Address:

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State:

City:

Zipcode:

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Please write 2-3 sentences describing why you are applying to the Re-creation Studio and what you hope
to gain from it.

I understand that I may or may not be selected to participate in the
Re-Creation Studio. If I am selected, I agree to attend all workshop
sessions as scheduled.

I agree (Yes):

You will be notified of day/time determination two weeks prior to the start date. All
sessions will be held at The Art Experience, Inc., 175 S. Saginaw #109, Pontiac, MI 48342.
248-706-3304.