Kindermusik Summer Enrollment Form

Child's First Name

*

Child's Last Name

*

Birthdate (MM/DD/YYYY)

*

Siblings Names/Birth Date, if enrolling for Family Time (children must be enrolled to attend class)

Parent's Last Name

*

Parent's First Name

*

Street Address

*

City

*

State

*

Zip Code

Main Phone (with area code)

*

Alternate Phone Number

E-mail Address

*

Medical Problems/Allergies?

How did you hear about Kindermusik?

*

Visited Kindermusik.com
Visited Kindermusik with Ms. Danielle Website
Facebook
Referred by a friend
Saw Ad in magazine
Other

If you selected "Other" or Referred by a friend", please explain:

Please select the appropriate age group for your child:

*

Select your first choice for class:

*

Select an alternate choice for class time:

*

I qualify for the following discounts:

I have more than one child enrolled this session.
I have referred a friend to your program. (List their name under Comments)

Payment options:

*

I would like to pay by credit card.
I would like to mail you a check before the session begins.

I give consent for photos or video to be taken during class for the purpose of sharing with other parents within the class. (No names will be identified and no photos or videos will be used for promotional purposes without your approval and consent.)

*

Yes No

I understand that I am responsible for paying in full for the class of my choice in a timely manner. No refunds are available except when written notice is given two weeks prior to the start of the class or under extreme circumstances.

*

Yes, I understand.

Comments