2012 Session March 5th June 30th NO CLASS JUNE 9th Please make checks payable to: SARA

RA QUINTANAR Check one: _____RETURNING FAMILY ____ NEW FAMILY Parents and/or Caregivers name(s) _______________________________________________ Address:_________________________ City, State, Zip:_________________________________ Phone:___________________________Alternate Phone Number: _______________________ E-mail:___________________________2nd E-mail address: _____________________________ First Registering Childs Name:____________________________ Birthdate:______________ Registering Sibling(s) names/Birthdates:____________________________________________ What are your childs favorite songs and what instruments do they enjoy? _________________________________________________________________________________
$_______ New and Retuning families 8 weeks One child - $100.00 One child + one sibling over 10 months - $150.00 $_______ Price per class (one day only) Subject to availability. One child: $15.00 per class or One child + one sibling over 10 months: $20.00 Please RSVP before attending class if you are not registered for the entire session to ensure a spot! Cancellation policy: If canceling before 1st day of class, you can receive a full refund (minus a $10 processing fee) After that time, for cancellations, I cannot give out refunds. Class Availability: Class schedule may be adjusted or canceled due to insufficient registration. If for any reason I must cancel a class, you will be notified ahead of schedule, and another class will be added to the session. Permission to Participate: I, the undersigned, consent to my childs participation in Music With Sara. I agree to hold the class, its contracted instructor, and other students harmless for liability, loss or expense incurred or suffered as a consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct, and execution of the music program. Permission is granted to Music With Sara to use any recording of performances by me/my child or audio/video taken of me/her/him while participating in the education programming, for use by Music With Sara. Medical Consent: While I understand that there are some risks inherent in the activities that are included in the program, but willingly assume these risks in order to allow me/my child to participate. If I cannot be reached in the event of an emergency, I give permission for any care or treatment by a physician, hospital, nurse, doctors assistant or medical care facility that may be required. Does your child have medical problems, or allergies of which we should have knowledge? ___Yes ___No If yes, please list: _____________________________________________________________________________ My signature designates that I have read and fully understand the above information and agree to assume all risks. Participant/Parent Signature:_____________________________________________________Date:_____________ Music With Sara (818) 795-9417 e-mail: musicwithsara@gmail.com www.musicwithsara.com Classes meet: 10:30 Saturdays at Yoga at the Village 1306 Sonora Ave at Kenneth Road - Glendale 91201

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