EmailMe Form - Creative Movement For Kids!

Parent's Name *
First Last
Home Phone
### - ### - ####
Email *
Mobile Phone *
### - ### - ####
Child's Name *
First Last
Child's Age *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
How Did You First Hear About This Class? *
Mailing
Facebook/Instagram
Flier
Friend
Google Search
Other (Please Describe Below):
Other:
Informed Consent and Hold Harmless/Release Agreement:
I understand that participation in movement activities involves a certain degree of risk. I have carefully considered the risk involved and I understand that participation in these activities is entirely voluntary. By printing my name below, I release the Wil-‐Mar Neighborhood Center and Chelsea Moten from any and all claims of liability arising out of my child's participation in this class. Photos may be taken during a session and I allow these to be used for educational and marketing purposes for both the Wil-Mar Neighborhood Center and B Bright Studios. *
I have read and agree to the above statement.
Any comments or questions?