Holiday Camp Enrollment Form

Child's First Name

*

Child's Last Name

*

Birthdate (MM/DD/YYYY)

*

List name and age of siblings attending:

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
Attended a Demo Class
Referred by a friend
Saw Ad in Hooray for Families
Brochure
Other

If you selected "Other", please explain:

Select your first choice for class:

*

Select an alternate choice for class time:

*

I qualify for the following discount:

I have more than one child enrolled in this camp.

Photo Consent

*

Yes, I consent to use of my child's image in advertising.
No, I do not consent to the use of my child's image.

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