Kindermusik with Claudia

*Child's First Name:

*Child's Last Name:

*Child's Birthdate:

*Parents' First Names:

*Parents' Last Name: Name:

*Address:

*City:

*Zip Code:

*Home Phone:

*Cell Phone:

Work Phone:

*Email Address:

Father's Occupation:

Mother's Occupation:

What formal music instruction has the child had (if any)?

Musical training of parents: Lessons / Instruments / Voice / Your interest:

How did you hear about Kindermusik with Claudia?

*Are there medical or behavioral conditions or food allergies of which the instructor

should be aware?

Press ENTER only when you are ready to submit the form.

If you wish to register more than one child, please use a separate form for each child.

Please select the class in which you would like to register your child.

Materials' costs are included in Semester Fees.

Newborn to 18 Months

18 Months to 3 Years

Begins Jan 26 & 27, 2010

PAYMENT METHOD

You may pay by personal check or by credit card.

If you are paying by personal check, please make it payable to:

Kindermusik with Claudia

Please mail check to:

Claudia Spinney

P. O. Box 170432

Arlington, TX 76003-0432

If you are paying by check or prefer to call in credit card information,

you have completed the registration process.

Please scroll down and click the "Submit Registration Form" button.

CREDIT CARD INFORMATION

Your payment will be processed only when your space in the class of your choice is confirmed.

WE ACCEPT VISA, MASTERCARD, DISCOVER CARD & AMERICAN EXPRESS.

Credit Card Number:

Expiration Date:

Month:

Year:

Name on Credit Card:

Billing Address of Credit Card:

City, State & Zip:

Apt. #:

When paying online with Credit Card, please enter the amount to be billed and all billing

information (as it appears on your credit card statement) in the fields below.

3 to 5 Years

Begins Jan 26 & 27, 2010

*First Names & Ages of Siblings:

*Required field

Amount:

15-week session fees: $220

15-week session fees: $230

Online Registration Form

with

Claudia

Arlington, Texas 817-478-3550