Kindermusik Play-date Enrollment

Child's First Name

*

Child's Last Name

*

Birthdate (MM/DD/YYYY)

*

List siblings between 6 mos and 6 years

Parent's First Name

*

Parent's Last Name

*

Street Address

*

City

*

State

*

Zip Code

Home Phone (with area code)

*

Alternate Phone Number

E-mail Address

*

Medical Problems/Allergies?

How did you hear about Kindermusik?

*

Referred by a friend
Saw magazine ad
Visited Kindermusik with Ms. Danielle Website
Visited Kindermusik.com
Received an E-mail
Saw it on Facebook
Other

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

Select the March play-date you wish to attend:

*

Saturday, Mar. 22 at 10 a.m.
Saturday, Mar. 22 at 11 a.m.
None

Select the April play-date you wish to attend:

*

Saturday, Apr. 26 at 10 a.m.
Saturday, Apr. 26 at 11 a.m.
None

Select the May play-date you wish to attend:

*

Saturday, May 24 at 10 a.m.
Saturday, May 24 at 11 a.m.
None

Select the June Part 1 play-date you wish to attend:

*

Friday, June 6 at 10 a.m.
Friday, June 6 at 11 a.m.
Saturday, June 7 at 10 a.m.
None

Select the June Part 2 play-date you wish to attend:

*

Friday, June 20 at 10 a.m.
Friday, June 20 at 11 a.m.
Saturday, June 21 at 10 a.m.
None

Payment options:

*

I would like to pay by check.
I would like to pay by credit card.

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