Karen Haughey Music Studio

Family music for babies - Winter/Spring 2019 REGISTRATION

Newborns - 18 months. 14 week session

Class time *

Child's Name *

Child's Name

First Name

Last Name

Child's Age, as of January 1, 2019 *

yrs.mos

Child's Birthdate *

Child's Birthdate

YYYY

School or Childcare Attended (indicate NA, if not applicable) *

Siblings

Optional

Sibling 1

First Name

Last Name

Birthdate

YYYY

Sibling 2

First Name

Last Name

Birthdate

YYYY

Parents, Guardians and Care Takers.

Parent/Guardian 1 *

Parent/Guardian 1

First Name

Last Name

Email *

Phone *

Phone

(###)

###

####

Alt. Phone

Optional

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2

Optional

First Name

Last Name

Phone

(###)

###

####

Caretaker or other adult accompanying child to class

Required information if child will not be accompanied by a parent or guardian.

First Name

Last Name

Phone

(###)

###

####

Additional Information

Are there any medical or behavior issues of which the teacher should be aware? *

Has your child had any prior music education?

How did you hear about Karen Haughey Music Studio *

+ Who referred you?

++ if "other", please explain

Payment Method *

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