Kids Meditation Registration Form

1

Classes between Dec 5 - Jan 30

Monday - 6.45PM - 7.45PM EST; Wednesday 6.45PM - 7.45PM EST

Monday Class Venue -11801 Emarald Green dr., Clarksburg, MD 20871 (Private Residence)

Wednesday Class Venue -

2

Photo Release Consent Please check only one of the following: I give my permission for my child’s name

YESNO

3

Which day are you interested ?* This field is required.

Monday 6.45 PM - 7.45PM EST

Wednesday 6.45PM - 7.45PM EST

4

Child's Full Name* This field is required.

First Name

Last Name

5

Child's Age* This field is required.

6

Parent's Name* This field is required.

First Name

Last Name

7

Parent's E-mail* This field is required.Updates will be sent to this email .

8

Additional Email (optional)Please provide an additional email, if you would want updates to be sent.

example@example.com

9

Parent's Phone Number* This field is required.

Area Code

Phone Number