Select Age Group and class time for a maximum of 2 children:
(Please put additional children on a separate form.)

Studio: South Surrey Returning New

Jollyjumpers (newborn to 18 months) / Class time and day: None Mon Jollyjumpers 9:45 Thu Jollyjumpers 10:30 Fees $199 / 16 weeks. (If paying by payment plan- Cheques only Deposit $65 plus post dated chqs for $33.50, dated the 15th of Feb-May)

Puddlejumpers (16 mo to 3 1/2 yrs) / Class time and day: None Mon Puddlejumpers 10:45 Thu Puddlejumpers 9:30 Fees $199 / 16 weeks. (If paying by payment plan- Cheques only Deposit $65 plus post dated chqs for $33.50, dated the 15th of Feb-May)

In the event that your class is full, please indicate another suitable class time(s): (optional)

Personal Information:

New families, how did you hear about us?

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Friend - Frient / Event Name:

Parents' Names: (first & last please)
Adult attending if not parent:
Email:
Phone:

Child's Name 1 (first and last)
Birthdate:
Child's Name 2 (first and last)
Birthdate:
Address: City:
Postal Code:

Payment information: **Please note that for security reasons, we do not advise dropping payments off with other merchants in our building.

• Sibling Discounts: If you are using payment plan, please make deductions from deposit.
• If you have more than one child registering, your first child pays full price. Your subsequent children deduct $20.
• I am registering a 2nd, 3rd or 4th child on this form and will be deducting $20 from my total.
  List any other coupons / discounts here:

Payment Amount :
Additional payment instructions / comments:

I will be paying by:

Payment Plan option: a deposit plus post-dated cheques (see fee schedule beside class above ) .
Please mail cheques to our mailing address at: Jump Start Music & Movement #74-1240 Falcon Drive, Coquitlam, BC V3E-2B4.

In full by cheque- (same instructions as payment plan)

In full by credit card - You will be automatically directed to the secure credit card page after submitting this form.

Policies:

Please click the link to the left to view our policy page.

I the undersigned have read and understood the attached policies and agree to the terms within. I wish to register my child for the class indicated. I understand that photographs taken in class may be used without financial compensation, unless ohterwise indicated by me in writing. Checking this box indicates my agreement that I will not hold Jump Start Music & Movement responsible for any loss, damages or injury incurred directly or indirectly from participation in the Jump Start Program. If paying by credit card, checking this box also constitutes authorization to charge said card.