Online Registration Form

Child #1 Name *

First & Last Name

Child #1 Birth Date *

Child #1 First Class Choice *

Child #1 Second Class Choice

Child #1 is... *

brand new to Kindermusik

returning

returning after absence

returning family, new sibling

Child #2 Name

First & Last Name

Child #2 Birth Date *

Child #2 First Class Choice *

Child #2 Second Class Choice

Child #2 is... *

brand new to Kindermusik

returning

returning after absence

returning family, new sibling

Child #3 Name

First & Last Name

Child #3 Birth Date *

Child #3 First Class Choice *

Child #3 Second Class Choice

Child #3 is... *

brand new to Kindermusik

returning

returning after absence

returning family, new sibling

Contact Information

Parent Name *

First & Last Name

Parent Name

First & Last Name

Address *

Street

Street Line 2

City

State

Zip

Phone Number *

Alternate Phone Number

Email Address *

Caregiver Name (if attending class with child)

First & Last Name

Do any of the children you are registering have special needs? Please explain.

Referred to Music Connections by:

Payment Preferences

Tuition Payment Method *

Cash or Check

Credit Card

Responsibility *

I understand that it is my responsibility to keep my credit card information up to date. Any delays in current information may result in payments beyond nine months or doubled charges in order for my account to remain current.

Type of Credit Card *

Credit Card Number (must be provided to process payments) *

Expiration Date *

Month

/

Year

Security Code (on back of card) *

Card Holder's Name *

As it appears on the card

Card Holder's Address *

Street

Street Line 2

City

State

Zip

Payment Plan

Monthly installments - credit card (charged during the first week of each month, September thru May)

Three-month bundles - credit card (charged the first week of Sept., Dec., and March for school year / 9 month enrollment)

Three-month bundles - cash/check (due Sept. 10, Dec. 10, and March 10 for school year / 9 month enrollment)

Photo Permission *

Yes, you have my permission to use photographs or video of my child from class for occasional promotional postings (no last names used).

No, please do not include my child in photographs or videos

Total Number of Children You are Registering? *

1

2

3

Discount for Multiple Registrations

$0

$10

$30

Choose $0 if you are registering only 1 child, $10 if you are registering 2 children, or $30 if you are registering 3 children.

Non Refundable Registration Fee Due Now (You will be directed to a page where you can securely pay with a credit card or Paypal) $

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