EmailMe Form - Toddlers in Motion!

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

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Tuition assistance is available. Please indicate below if you are interested in learning more about this option.
How Did You First Hear About This Class? *
Mailing
Flier
Facebook/Instagram
Ms. Cindy's Email
Word of Mouth/Friend
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 Ms. Cindy 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. *
I have read and agree to the above statement.
Any comments or questions?