Studio Attending: Coquitlam Maple Ridge
Returning Family
New Registration - If new, how did you hear about us?
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Friend - Friend / Event Name:

Child's Name: (not necessary for fitness)
Child's Birthdate: d/ m/ y /
Parent Name 1: First Last
Parent Name 2: First Last
Address: City:
Postal Code: Phone:
Email:

Please select the programs you wish to attend:

Jollyjumpers Coquitlam - CQ Jolly Sat 10:45 CQ Jolly Wed 9:30-New CQ Jolly Wed 10:45-FULL CQ Jolly Thu 9:30-FULL Session I (Starts June 14/18/19)
Puddlejumpers Coquitlam - CQ Puddle Sat 9:30 CQ Puddle Sat 10:45 FULL CQ Puddle Thu 10:30 Session I (Starts June 14/18/19)
Cycle of Seasons Coquitlam - CQ Cycles Sat 9:30 Session I (Starts June 14)
Piano- Play & Practice Coquitlam - Play & Practice Wed 5:45 Session I (Starts June 18)
Piano- Tuning Up Coquitlam - Tuning Up Wed 6:45 Session I (Starts June 18) ** Year II
Jollyjumpers Coquitlam - CQ Jolly Fri 12:15pm CQ Jolly Fri 10am Session II (Starts July 11)
Puddlejumpers Coquitlam - CQ Puddle Fri 11am Session II (Starts July 11)

Jollyjumpers Maple Ridge - MR Jolly I Fri 10:30 Session I (Starts June 20)
Jollyjumpers Maple Ridge - MR Jolly II Thu 9:45 Session II (Starts July 10)
Puddlejumpers Maple Ridge - MR Puddle I Fri 9:30 am Session I (Starts June 20)
Puddlejumpers Maple Ridge - MR Puddle II Thu 10:45 Session II (Starts July 10)

Number of Classes Attending: - 8 classes Cycles $86 8 classes Jolly or Puddle or Fit $70 6 classes Cycles $72 6 classes Jolly or Puddle $60 4 classes Play & Practice $55 4 classes Tuning Up $75
Choose from 6 or 8 weeks of each category. ** All piano classes are 4 weeks.

If you are taking 6 classes, please list the two dates you will not attend:

Referring 5 buddies to come for free? List buddies here so we can watch for their registrations. If they register within 1 week of you (they must be new to Jump Start and put your name in the referral section of the form above to qualify) you will get your summer session free! Names to watch for:

Payment information

Coupons / Discounts (Please include coupon number and amount.)

Payment Amount: $

Chq (Mail to Jump Start Music #74-1240 Falcon Dr, Coquitlam , BC V3E-2B4)
Credit Card (If paying by credit card, you will be connected to our secure server after submitting this form.)

Please view our policies at the link to the right

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.