Personalized Video Request

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Personalized Video Request

PLEASE READ CAREFULLY AND PROVIDE ALL INFO. ONCE RECEIVED A TEAM MEMBER WILL REACH OUT TO YOU FOR THE PRONUNCIATION OF YOUR CHILD'S NAME. ONCE PAYMENT IS RECEIVED OUR TEAM WILL NOTIFY MS. HOUSTON AND SHE WILL BEGIN MAKING THE VIDEO.

19Questions

1
Parent/Guardian Full Name* This field is required.
First Name
Last Name
2
Parent/Guardian Phone Number* This field is required.Your phone number will remain completely confidential. We'll only use it to contact you if we have any additional questions about your request.
Area Code
Phone Number
3
* This field is required.
mother
father
grandmother
grandfather
aunt
uncle
sister
brother
cousin
friend
neighbor
teacher
4
Child's First Name* This field is required.
5
Child's Nick Name* This field is required.(Type N/A if they go by their first name only)
6
Child's Age* This field is required.(For birthday requests, please enter the age they will be turning)
Please Select
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9
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7
Child's Birthday* This field is required.(Enter the date like “January 9th”. Type N/A if this is not a birthday video request)
8
Occasion of the video* This field is required.
Birthday
Lost a tooth
Good Grades
Potty training success
New sibling
Holiday Greetings (Christmas, Easter etc)
Sports achievement/ Team success
Graduation
Encouragement / Motivation
First day of school
Moving to a new house
Other
9
Child's favorite color* This field is required.(Enter the date like “January 9th”. Type N/A if this is not a birthday video request)
10
Child's favorite interests right now* This field is required.(Examples: Puppies, Teddy bears, Dinosaurs, Trucks, Baby dolls)
11
Child's favorite foods* This field is required.
12
Child’s Favorite Song(s) or Video by Learning with Ms. Houston* This field is required.
13
Any Additional information* This field is required.(Anything else that would help us make this video as personal and special as possible for your child? If nothing put n/a.)
Huge
Large
Normal
Small
Ok
Ok
14
When do you need the video delivered by?* This field is required.
Date
Year
Month
Day
15
I understand that all payments for videos are non-refundable.* This field is required.
I understand and agree
16
I give permission for Ms. Houston to create a personalized video for my child based on my request..* This field is required.
I understand and agree
17
Electronic Signature* This field is required.By signing your full name below, you are electronically signing this form and confirming that all the information provided is accurate. You also agree to the statements and permissions given above.
18
Today's date
Date
Year
Month
Day
19
My Products
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