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

Studio: - St Andrews - 1044 St George's Alchemy Centre Returning New

Jollyjumpers (newborn to 18 months) / Class time and day: (Alchemy Centre) None Alchemy 8 weeks Thu 10:30 Jollyjumpers Alchemy 6 weeks Thu 10:30 Jollyjumpers Fees $66/ 6 weeks / $77 / 8 weeks

If choosing 6 weeks, please list the 2 weeks you'll miss:

All Together Now (Mixed age 1-4yrs) - Wed 9:30 ATN June 4-25 Wed 9:30 ATN Aug 7-28 $44/ child 4 weeks (St Andrews)

Puddlejumpers (16 mo to 3 1 /2 yrs) / Class time and day: None $44 / child 4 weeks (St Andrews)

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

Personal Information:

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.

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

Payment Amount :
Additional payment instructions / comments:

I will be paying by:

In full by cheque- (MAIL TO #74-1240 Falcon Drive, Coquitlam, BC V3E-2B4)

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 / Alchemy Centre 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.