Registration Form

Registration Form

Tots and Toddlers Music Time for children 18 mos to less than 4 years

Class time:  Tuesdays 9:00-9:45   OR    Tuesdays 10:00-10:45

Dates: TBA

Cost:  $100 (includes tuition and instrument) + $10 registration fee for new students

Location: Scout Room at the Waverly Community House (www.waverlycomm.org)

Child’s Name:                                                            Date of Birth:________    

Parents Names:_____________________________________________                                                                                                                        

Address:____________________________________________

___________________________________________________                                                                                                                                 

Phone:                                Email _____________________________

How did you hear about it?                                                           

Class Time Choice: 1^st Choice:________ 2^nd Choice   _________  can do either _____

On the back please list any additional concerns including medical needs or allergies which may help in planning this class or call to discuss these in details.

KidsMusic with Karen Kane

www.kidsmusicwithkarenkane.orbitaltec.net

email: karen@kidsmusicwithkarenkane.orbitaltec.net

(570) 586-1051

Release: I/we do not, will not hold any individual associated with KidsMusic, the

Waverly Community House or Board of Trustees, volunteers or Abington Township responsible for any accident or injury incurred by myself or my child while participating in this Class.

Parent/Guardian Signature:____________________________________

Registration is closed when class maximum is reached.

Enrollments will be confirmed in the order that registrations are received.

To reserve a space, print and mail this signed registration form with check payable to

Karen Kane.  

Mailing Address:106 Apple Valley Circle,

Clarks Summit, PA 18411                                                                                    Thank You!