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

Studio: Coquitlam Returning New

Attending 6 or 8 weeks? (If 6 weeks, please indicated the dates you will NOT attend.

Jollyjumpers (newborn to 18 months) Select One Saturday 11:45 JJ Wed 10:45 JJ 6 weeks $72, 8 weeks $80 No materials are handed out in shorter, summer classes. Add a super value package for $17.95 below!

Puddlejumpers (16 mo to 3 1/2 yrs) / Class time and day: None (1)Sat 10:45 Puddlejumpers (1)Mon 5:45 Puddlejumers (1)Wed 9:30 Puddlejumpers 6 w eeks $72, 8 weeks 80. No materials are handed out in shorter, summer classes. Add a super value package for $17.95 below! Please note that the Monday evening class is only 7 weeks @ $77

Cycle of Seasons (3 to 5 yrs) / Sat 9:30
6 weeks 84, 8 weeks 96. No materials are handed out in shorter, summer classes. Add a super value package for $17.95 below!

Family Music & Bed-Time Story All ages. Mondays 6:45pm Designed for siblings. 6 weeks $72 /7 weeks $77 (2nd child saves 50% on tuition) No materials are handed out in shorter, summer classes. Add a super value package for $1..95 below!

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 your 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 within 10 business days of submitting this form will result in cancellation of registration.

5 friends coming? List them here to particpate in our 5 friends offer:

Class Fee :
Super Value Package Fee: **If you would like more than one package, please comment here.
Package A (jumbo ball + large egg shaker) $17.95

Total Cost: :

Additional instructions / comments:

I will be paying by:

In full by cash- Drop payment at our 98 Brigantine Drive location on Mondays from 9:30-12; or Thu from 9:30-12.

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:

Please right click the underlined link above to view our policy page in a new window. **Please read policies carefully before submitting registration.

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.