REGISTRATION FORM FOR KINDERMUSIK CHILD DEVELOPMENT CLASSES PRESENTED BY MUSIKANDMOTION IN NATOMAS, RANCHO CORDOVA & WEST SACRAMENTO, CALIF.   PRINT AND FILL OUT THIS FORM. PLEASE MAKE CHECKS PAYABLE TO SUNNY S. KIRA.   FAX TO: 530-756-9140; OR MAIL TO: DAVID KIRA, C/O M&M @ Med. Vis. Tech., 635 ANDERSON RD. SUITE 1, DAVIS, CA 95616.   INFORMATION: 916-419-6999.

Parent(s) or Caregiver Name:

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Street address:

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City/State/Zip:

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Telephones:

 Home: _______________________________ Work/Cell: ____________________________

Email Address:

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Adult(s) attending class
other than parent or caregiver:

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Child's Name:

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 Gender: _______________________ Date of Birth: ________________________________

First Class Choice:

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(Please Include Your Second Class Choice in case your 1st choice is full or does not meet minimum enrollment) :

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Location:Natomas, Rancho Cordova or West Sacramento

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Special Needs or Allergies:

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Sibling's Name:

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 Gender: _______________________ Date of Birth: ________________________________

Sibling's Name:

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 Gender: _______________________ Date of Birth: ________________________________

If new, how did you hear about us (We like to thank famiilies for their referrals!)?

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Each Kindermusik class offers you and your child many unique benefits. What are your goals for enrolling this semester? 
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_____ Please initial here if Musikandmotion may include images of you and your child on our website or blog.

I have read and agree with Musikandmotion's studio policy. I do hereby release and forever discharge Musikandmotion, the studio instructor, and the studio owners, from any and all actions, claims and demands for, upon or by reason of damage, loss of personal injury which may be sustained by my child or myself during the course of or as a result of this musical activity.

I understand the deposit includes the cost of At-Home Materials from Kindermusik which are NON-REFUNDABLE or TRANSFERABLE to the next semester, and that missed classes may be made up only within the current semester of enrollment. Full payment is due on or before the first day of class.

Name: _____________________________________________ Date: __________________________________________