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Haworth: SUMMER '19 Registration
Please use this form to register for Music Speaks Summer 2019 Classes at the Haworth Library, 165 Stevens Place, Haworth, NJ 07641
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Email
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Your email
Parent/Caregiver (First & Last Name):
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Your answer
Street:
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Your answer
City:
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Your answer
Zip Code:
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Your answer
Parent Home Phone:
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Your answer
Parent Cell Phone:
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Your answer
Emergency Contact (First & Last Name):
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Your answer
Emergency Contact Phone Number:
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Your answer
Child's Name (First & Last):
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Your answer
Date of Birth:
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MM
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DD
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YYYY
Photo Consent (please indicate Yes or No):
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Yes
No
Allergies:
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Your answer
Class Selection (First Choice):
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Choose
Tuesday @ 4:00pm
Wednesday @ 9:15am
Wednesday @ 1:00pm
Class Selection (Second Choice):
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Choose
Tuesday @ 4:00pm
Wednesday @ 9:15am
Wednesday @ 1:00pm
Do you have questions for Wendy?
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By registering and signing below, you are authorizing your child to participate in all class activities. You assume all risks normal to these activities and absolve Music Speaks LLC of all present and future liability in the event of accident or injury.
Parent or Caregiver Signature
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