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

Studio: Coquitlam Returning New

Infant Massage Class- Pre-crawlers (Healed umbilicus)
: Time & Day None 4 weeks 60 min classes $100 per child. (Twins will need 2 care-givers for this class. 2nd baby pays $50)

If your child has any health concerns, please explain: (ie-premature, seizures, illness, etc.)

Sign Language 0-18 months
Time & Day: None 4 weeks 45 min class $75 per child. (Siblings pay $55)

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: ***optional
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's fees listed above
  List any coupons / discounts here:

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:

In full by cash- Drop payment at our 98 Brigantine Drive location on Mondays from 9:30-12; Tuesdays-Wednesdays from 5pm-9pm or

In full by cheque- Please mail cheques to our mailing address at: Jump Start Music & Movement #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:

• Cancellations: Cancellations made at least 14 days before the event will be refunded in full. Cancellations made after this time are subject to a $15 administration fee, plus class fees for any classes attended.
• Occasionally photos are taken in class and may be used for promotional purposes without remuneration unless otherwise indicated by the attendee in writing.
• Please notify us if your child has any health concerns. If your child is ill with a contagious illness, fever or substantial nasal mucous, please contact us and refrain from attending class.

I the undersigned have read and understood the attached policies and agree to the terms within. I understand that cancellations are charged a $15 fee, plus fees for any classes attended. I have disclosed any health concerns that may prevent my child from participating safely in Jump Start programs. 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.