On-line Registration for Fall Semester 2013

Please fill out the FALL FORM below and submit. One of our MAGIC team members will contact you shortly to confirm course availability.

Previously enrolled at MAGIC
Yes No  
Child's name
Birth date
/ /   Age Sex M F
School and/or current program    
Primary Email Address* * required
Home Address
Apt#
City State Zip
Mother's Name
E-mail
Home Phone Work   Cell
Father's Name
E-mail
Home Phone Work Cell
Alternate Address
Emergency Contact    
Phone Cell
Physician's Name
Phone
Participating adult and/or person authorized to pick up child
Phone
What's the best way for us to contact you?
Mother's Email Mother's Phone
Father's Email Father's Phone
Other
   
PLEASE CHECK APPROPRIATE BOXES
Does your child take any medications regularly?
Yes No  
Name of medication, dosage
Condition medication is for
Are there any allergies or health conditions that we should be aware of?
Yes No  
If yes, please describe
Eyeglasses
(Should they be worn during their lessons?)
Yes No  
Contact lenses
(Should they be worn during their lessons?)
Yes No  
Dental Appliances
Yes No  
If yes, please describe
Hearing Aids
Yes No  
Please list any physical conditions we should be aware of
 
CLASS INFORMATION
 
Age Group
  6-18 months
  18-26 months
  2-3.5 Years
  3-5 Years
  6-early teens
       
Name of Class
Name of Additional Class
   
PAYMENT INFORMATION
Class Day Time Fee
All MAGIC Gymnastics Classes (for Baby Gym, please see below)

First Class Per Week


Additional Class Per Week


















$


$
All MAGIC Creative Classes and Baby Gym Classes

First Class Per Week


Additional Class Per Week


















$


$
MINI MAP CLASSES

MINI MAP CLASSES, DOUBLE TIME or BUSY BEE

Please use Ctrl Key to select multiple days




MINI MAP CLASSES, TODDLER TIME

Please use Ctrl Key to select multiple days
















$ $
MAP CLASSES

MAP CLASSES, MY OWN TIME

Please use Ctrl Key to select multiple days




MAP CLASSES, CLASSROOM KIDS

Please use Ctrl Key to select multiple days
















$ $
DROP-IN CLASSES





















$


Total Due     $
 

Payment Methods
When completing payment details below, you must choose either Credit Card OR Coupon/Voucher so we can properly process your registration. Please do not check both options. Any applicable discounts will be applied to credit card payments.

Credit Card

   
Name on card Billing Zip Code
   
Card # Security #
   
Exp.Date (Month/Year):

Coupon/Voucher

Coupon/Voucher Description

Issued by (MAGIC or other, please specify)

Coupon/Voucher Number (if applicable)

Additional Information

I understand and accept all enrollment conditions*
Parent or Guardian Name* Date*
*required
Please email me event information and schedule updates.
       
 
Submitting this registration for classes acknowledges acceptance of all enrollment conditions, payment, refund and insurance policies at 74th St. MAGIC.
>>>>>>>>>>>>>>