Name Parent/Guardian 1 *

First Name

Last Name

Cell Phone: Parent/Guardian 1 *

(###)

###

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Work Phone: Parent/Guardian 1 *

(###)

###

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Name: Parent/Caregiving Attending Program *

First Name

Last Name

Cell Phone: Parent/Caregiver Cellphone *

(###)

###

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Child's Name *

First Name

Last Name

Child's Gender

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does Child Receive Special Services

No

Speech

OT

PT

Other

Program (please select) *

Semester Programs Children 12-24mth with Parent/Caregiver. Guided learning through play, music and movement with experience teachers and professional musicians.

Sept- Dec (13 Sessions): Tuesdays @ 9:30am - 11am, $400 per semester (Dates: September 17, 24, October 1, 8, 15, 22, 29, November 12, 19, 26, December 3, 10, 17)

Child 2 Name

First Name

Last Name

Child 2's Gender

Male

Female

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 2 Home Phone

(###)

###

####

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other

Program (please select)

Semester Programs Children 12-24mth with Parent/Caregiver. Guided learning through play, music and movement with experience teachers and professional musicians.

Sept- Dec (13 Sessions): Tuesdays @ 9:30am - 11am, $400 per semester (Dates: September 17, 24, October 1, 8, 15, 22, 29, November 12, 19, 26, December 3, 10, 17)