Fall 2019 Enrollment Registration Form

To register, please complete this form. Confirmation will be sent by e-mail once payment has been received. For more information, call 212-721-1223 ext. 218 or visit www.cmom.org

Parent 1 Name*

First NameLast Name

Parent 2 Name

First NameLast Name

Are you a CMOM Member?

YesNo

CMOM Membership Expiration Date (If applicable)

Child's Full Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Preferred Phone Number*

Area CodePhone Number

Secondary Phone Number

Area CodePhone Number

If a caregiver will be accompanying your child to class, please print his or her name:

Caregiver's Name

First NameLast Name

Caregiver's Phone Number

Area CodePhone Number

Class Title

Semester

Day (Check all that apply)*

Time*

Second Class Choice

Please select a second choice of time and day for Preschool Prep and Science Explorers Classes.

Class Title

Semester

Day (Check all that apply)

Time

I agree to the terms and conditions listed below *

Agree

*Cancellations must be made before the second scheduled class to receive a refund.

*There is a withdrawal fee is $100 per class for any cancelations.

*For gentle separation classes, a parent or caregiver must attend classes with the child.

*No siblings please, unless enrolled.

*CMOM reserves the right to cancel under-enrolled classes.

*CMOM members receive a special rate on classes. If you are not a member, please join by calling 212-721-1223 ext. 227 or visit www.cmom.org.

*CMOM is closed to the public on Mondays; therefore, class members will not be permitted to explore exhibit areas before or after class.

*One make-up (reserved at least 24 hours in advanced) is permitted per child per class within a semester.

Fall 2019 Classes

Fall 2019 Classes: First Choice

Preschool Prep (Gentle Separation) - ages 2-3Science Explorers (Drop-Off) - ages 3-4Rock with Me Baby Music Class with Mike Messer - ages 0-3 - 9:00-10am - $200 (non-members) $160 (members)

Fall 2019: Preschool Prep Days/Times

Mondays & Wednesdays, 10am-12pmTuesdays & Thursdays, 10am-12pmFridays, 10am-12pm *extra 10% off for Friday add on class!

Fall 2019: Science Explorers Days/Times

Mondays & Wednesdays, 9:30am-12pm- $3,105 (non-member) $2,565 (member)Tuesdays & Thursdays, 9:30am-12pm-$3,565 (non-member) $2,945 (member)

Fall 2019 Classes: Second Choice

Preschool Prep (Gentle Separation) - ages 2-3Science Explorers (Drop-Off) - ages 3-4Rock with Me Baby Music Class with Mike Messer - ages 0-3 - 9:00-10am - $200 (non-members) $160 (members)

Fall 2019: Preschool Prep Days/Times

Mondays & Wednesdays,10am-12pmTuesdays & Thursdays, 10am-12pmFridays, 10am-12pm *extra 10% off for Friday add on class!

Fall 2019: Science Explorers Days/Times*

Mondays & Wednesdays, 9:30am-12pm- $3,105 (non-member) $2,565 (member)Tuesdays & Thursdays, 9:30am-12pm-$3,565 (non-member) $2,945 (member)

Coupon Code

Payment*

USDFall Enrollment Payment Amount

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How did you hear about classes at CMOM?*

How did you hear about us?

This helps us spread the word!