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

Studio: Coquitlam Returning New

Jollyjumpers (newborn to 18 months) / Class time and day: None Monday 9:45 Jollyjumpers Monday 12:30pm Jollyjumpers Monday 5:45pm Jollyjumpers Tuesday 9:45 Jollyjumpers Wednesday 10:45 Jollyjumpers Thursday 10:45 Jollyjumpers Thursday 12:30 Jollyjumpers Saturday 10:45 Jollyjumpers Saturday 12:30 Jollyjumpers Fees $195 / 16 weeks. Payment plan: Deposit $65 plus post dated chqs for $32.50 dated the 15th of Sept, Oct, Nov, Dec. CD- MY MUSICAL WORLD

Puddlejumpers (16 mo to 3 1/2 yrs) / Class time and day: None Monday 9:45 Puddlejumpers Monday 10:45 Puddlejumpers Monday 5:45 Puddlejumpers Monday 6:45 Puddlejumpers Tuesday 11am Puddlejumpers Wednesday 9:30 Puddlejumpers-FULL Thursday 9:30 Puddlejumpers Thursday 10:45 Puddlejumpers Saturday 9:30 Puddlejumpers Saturday 10:45 Puddlejumpers Saturday 12:30pm $195 / 16 weeks. Fees $195 / 16 weeks. Payment plan: Deposit $65 plus post dated chqs for $32.50 dated the 15th of Sept, Oct, Nov, Dec. CD DANCE WITH ME

Cycle of Seasons (3 to 5 yrs) / Class time and day:
None Monday 10:45 Cycles- Monday 6:45 Cycles Thursday 9:30 Cycles Saturday 9:30 Cycles Saturday 12:30 Cycles Fees $215 / 16 weeks. *Payment plan: Deposit $65 plus post dated chqs for $37.50 dated the 15th of Sept, Oct, Nov, Dec. ***BRAND NEW CD'S - WIND DANCERS I

First Notes 5&6 years / Class time and day: None Thu 5:15pm First Notes Thu 6:45pm First Notes Sat 9:30am First Notes Fees $430 / 32 weeks. *Payment plan: Deposit $70 plus post dated chqs for $45 dated the 15th of Sept, Oct, Nov, Dec. Feb, Mar, Apr, May.

Keyboard 7-10 years None Year I Tues 6:45pm Year I Wed 5:15pm Year 2 Wed 6:45pm Year 2 Thu 5:15pm Year 3 Tue 5:15pm Fees $715 / 36 weeks. *Payment plan: Deposit $115 plus post dated chqs for $60 dated the 15th of Sept through June.

Piano for Adults (non-performance based) None Piano - Adult Tue 8:15pm Piano- Adult Thu 6:45pm Fees $430 / year (32 weeks). *Payment plan: Deposit $70 plus post dated chqs for $45 dated the 15th of Sept, Oct, Nov, Dec. Feb, Mar, Apr, May. ** If you have children attending our program, you are eligible for the $20 family discount for yourself (take from deposit amount.)

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?

Print Ad Event Internet

Friend - Frient / Event Name:

Parents' Names: (first & last please)
Adult attending if not parent:
Email: Phone:
Cell /pgr: ***Parents with Cycle of Seasons and older children must leave a cell/ pager number if they intend to leave the waitng room during their child's class.
Address: City:
Postal Code:

Child's Name 1 (first and last)
Birthdate:
Child's Name 2 (first and last)
Birthdate:

Payment information: **Please note that for security reasons, we do not advise dropping payments off with other merchants in our building. Payments not received in FULL (including all post-dated cheques) within 10 business days of submitting this form will result in cancellation of registration.

• If you have more than one child registering, your first child pays full price. Your subsequent children deduct $20. If you are using payment plan, please make deductions from deposit.)
• If an older child has already recieved the specific CD listed above, you may deduct $10 and not receive the cd for the younger sibling.

I am registering a 2nd, 3rd or 4th child on this form and will be deducting $20 from my total.
List cd or any other coupons / discounts here:

Taking advantage of our 5 Friends Free Fun Offer? Have 5 friends new to Jump Start who will be registering on Nov 30? Let us know who to watch for:

Payment Amount :
Additional payment instructions / comments:

I will be paying by:

Payment Plan option: a deposit plus post-dated cheques (see fee schedule above) .
Please mail cheques to our mailing address at: Jump Start Music & Movement #74-1240 Falcon Drive, Coquitlam, BC V3E-2B4. (Alternately, you may drop payment at our 98 Brigantine Drive location during office hours.)

In full by cash- Drop payment at our 98 Brigantine Drive location during office hours: Wed 5-9pm or Thurs 4-8pm, Friday 10-12am, or give to your current teacher.

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 right click the underlined link above to view our policy page in a new window. **Please read policies carefully before submitting registration. There are no exceptions to our refund policy without a medical note.

I the undersigned have read and understood the attached policies and agree to the terms within. I understand that no refunds are issued after the start of the 2nd class. I wish to register my child for the class indicated. I understand that photographs taken in class may be used without financial compensation, unless otherwise 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.