Music With Me
REGISTRATION — OCT/NOV 2008

INSTRUCTIONS: Print this form by clicking on "File", then "Print" on your computer menu bar.
Fill out the form and mail it with payment of $30 to
The Joy of Music LLC, 108 West Main St Suite A, Washington, IA 52353


NAME OF CHILD 

DATE OF BIRTH   CURRENT AGE 

CLASS SESSION (check one)   If between age groups, please select the group that best suits your child's needs.
Monday:
 9:30 AM (0-18 months)
 10:30 AM (18-36 months)
 
 
Wednesday:
 4:00 PM (3-5 years)
 5:00 PM (0-18 months)
 6:15 PM (18-36 months)


ACCOMPANYING ADULT 

RELATIONSHIP TO CHILD 

MAILING ADDRESS 


PHONE   ALT. PHONE 

RELIGIOUS PREFERENCE (optional) 
(Religious information is used  only  to make appropriate musical selections.)


Permission to photograph:
I[do] [do not]  (circle one)  give permission for (child and/or accompanying adult) to be photographed during sessions of Music With Me.  Photos will become the property of The Joy of Music, LLC and may be used for advertising purposes including, but not limited to, The Joy of Music, LLC website, fliers and mailings.

Assumption of Risk and Waiver of Liability:
Iacknowledge that participation in this program requires my own alertness to the safety of my child(ren) and therefore hereby release The Joy of Music, LLC from such responsibility.

By signing below I agree to all terms and conditions above.

Signature  Date
(parent or guardian)