Kindermusik Fall Enrollment Form

Child's First Name

*

Child's Last Name

*

Birthdate (MM/DD/YYYY)

*

List siblings, if enrolling for Family Time:

Father's First Name

Father's Last Name

Mother's First Name

Mother'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?

*

Visited Kindermusik.com
Visited Kindermusik with Ms. Danielle Website
Saw Ad in Hooray for Famlies
Saw Yellow Tri-fold Brochure
Referred by a friend
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:

*

Select a payment plan:

*

I will pay in full.
I will pay a $60 deposit and the remainder in 3 payments or less during the session.

I qualify for the following discounts:

I referred a friend to get $15.00 off.
I have more than one child enrolled this semester (not including Family Time).
I have a child currently enrolled at Little Learners MDO. (20% off)

Payment options:

*

I would like to mail you a check.
I would like to pay on-line by credit card.

Photo Consent(no names included in captions)

Yes, I consent to the use of photos of my child in ads, brochures, web pages, etc.
No, I do not consent to the use of photos of my child.

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