Mommy
& Me

Registration Form - Winter 2010

To enroll, please complete this registration form and return with payment via mail or fax. You may also register in person or over the phone.

Parent/Guardian Name:

Mailing Address:

City and State:

Zip:

Home Phone:

Email Address:

Child's Name:

Date of Birth:

Second Child's Name:

Date of Birth:

Third Chld's Name:

Date of Birth:

Allergies, please describe:

Class:

Wednesdays, 10:30 AM – 11:30 AM (1/27 - 3/3)

One Child: $60.00
Each Additional Child: $50.00 X ___ = _____

Total Cost:

Payment Method:

Credit Card (VISA, MC or American Express)
Cash

If paying by credit card:

Cardholder Name:

Credit Card Number:

Credit Card Expiration:

3-Digit Security Code

Tuition is non-refundable after the first class. There are no refunds for student absences. Students may schedule make-up classes in another class.

I am enrolling my child for the entire session of Mommy & Me and understand that my non-refundable payment(s) is/are due accordingly.

Signature

35 LaCrue Avenue
Glen Mills, PA 19342

610-358-3501 / 610-358-3518 (Fax)
www.oasisfamilyfun.com