Hopwood Child Care

Music Together of Hopwood

Registration
Basic Information
Child 1 Name *

First Name Middle Name Last Name
DOB *

Month Day Year
Date
Gender *
Male / Female
Child 2 Name

First Name Middle Name Last Name
DOB

Month Day Year
Date
Gender
Male / Female
Parent 1 Name *

First Name Last Name
Parent 1 Phone Number *

Area Code Phone Number
Parent 1 E-mail *
Parent 2 Name

First Name Last Name
Parent 2 Phone Number

Area Code Phone Number
Parent 2 E-mail
example@example.com
Family's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are there special health needs for anyone (child or parent) attending Music Together classes?
Are there any allergies for anyone (child or parent) attending Music Together classes?
*

I certify under penalty of perjury that all information above is true and correct. I understand this application for Music Together of Hopwood will not be complete until I have submitted my $10 non-refundable registration fee. Once the registration fee has been received, my family will then be considered for Music Together class and/or placed on the waiting list.
Signature

Clear
If not paying online, please make checks payable to:

Hopwood Child Care

Mail to:

Hopwood Child Care

103 Hopwood Fairchance Rd

Hopwood, PA 15445
Should be Empty:

Music Together of Hopwood