Child's Name: ___________________________________________________________________

Date of Birth: ___________________________________________________________________

Parent/Caregiver: ________________________________________________________________

If currently enrolled, skip to Camp Registration or update contact info below:
Address: ________________________________________________________________________

City/State/Zip: ___________________________________________________________________

Home or Cell Phone: ______________________________________________________________

Email Address: ___________________________________________________________________

New to Program/Referrred by: _____________________________________________________

Camp Registration: Please indicate which camp(s) you are enrolling for the summer.
□ Adventure Summer Camp A ONLY
□ Adventure Summer Camp B ONLY
□ BOTH Adventure Summer Camp A & B (Receive $10 off tuition! Your deposit for both camps is required at time of registration.)

Classes:
For ages newborn to 20 months: Peek-a-Boo, I Love You & Busy Days ($135 each with $40 deposit)
For ages 18 months to 4 years: Creatures in My Backyard & Splash! ($135 each with $40 deposit)
For ages 3.5 to 6 years: Confetti Days & Sounds Abound ($150 each with $45 deposit)

Preferred Class Day and Time: _____________________________________________________
Alternate Class Day and Time Choice: _______________________________________________

Payment Method: □ Check □ Credit Card (payment in full only) : □ Visa □ Mastercard

Card # _________________________________________ 3-Digit Code ____________________

Expiration Date ________________________ Name on Card ________________________________

PLEASE MAKE CHECKS PAYABLE TO SUNNY S. KIRA.   Please bring form and deposit to class. If faxing: 530-756-9140; or mail to: DAVID KIRA, C/O M&M @ Med. Vis. Tech., 635 ANDERSON RD. SUITE 1, DAVIS, CA 95616. 

* 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 A NON-REFUNDABLE deposit is required at time of registration to secure my child's space in class and to order my home materials.

Name: ___________________________________________ Date: ________________________________