Summer 2017 Registration Form

Child #1 Name *

First & Last Name

Child #1 Birth Date *

Child #1 Summer Camp

Child #1 Second Choice (if my first is unavailable)

Child #1 Second Summer Camp (attending multiple camps this summer)

Child #1 Second Choice (if my first choice is unavailable)

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 Summer Camp *

#2 Second Class Choice (if my first choice is unavailable)

Child #2 Second Summer Camp (attending multiple sessions this summer)

#2 Second Choice (if my first choice is unavailable)

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 Summer Camp

Child #3 Second Choice (if my first choice is unavailable)

Child #3 Second Summer Camp (attending multiple sessions this summer)

Child #3 Second Choice (if my first choice is unavailable)

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

Repeat Enrollment

Check here if you are enrolling siblings in the same class.

Photo Permission *

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

Total Number of Children You are Registering? *

1

2

3

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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