74th St. MAGIC - REGISTRATION

On-line Registration for Summer 2013

Please fill out the form below and submit. One of our MAGIC team members will contact you shortly to confirm course availability.

Previously enrolled at MAGIC

Yes

Child's name

Birth date

Age

Sex

School and/or current program

Primary Email Address*

* required

Home Address

Apt#

City

State

Zip

Mother's Name

E-mail

Home Phone

Work

Cell

Father's Name

E-mail

Home Phone

Work

Cell

Alternate Address

Emergency Contact

Phone

Cell

Physician's Name

Phone

Participating adult and/or person authorized to pick up child

Phone

What's the best way for us to contact you?

Mother's Email

Mother's Phone

Father's Email		Father's Phone
Other

PLEASE CHECK APPROPRIATE BOXES

Does your child take any medications regularly?

Yes

Name of medication, dosage

Condition medication is for

Are there any allergies or health conditions that we should be aware of?

Yes

If yes, please describe

Eyeglasses
(Should they be worn during their lessons?)

Yes

Contact lenses
(Should they be worn during their lessons?)

Yes

Dental Appliances

Yes

If yes, please describe

Hearing Aids

Yes

Please list any physical conditions we should be aware of

CLASS INFORMATION

Age Group

		6-18 months
		18-26 months
		2-3.5 Years
		3-8 Years

Name of Class

Name of Additional Class

PAYMENT INFORMATION

Class	Day	Time	Fee
All MAGIC Gymnastics Classes (for Baby Gym, please see below) First Class Per Week Additional Class Per Week			$ $
All MAGIC Creative Classes and Baby Gym Classes First Class Per Week Additional Class Per Week			$ $
MINI MAP CLASSES MINI MAP CLASSES, DOUBLE TIME or BUSY BEE Please use Ctrl Key to select multiple days MINI MAP CLASSES, TODDLER TIME Please use Ctrl Key to select multiple days			$ $
DROP-IN CLASSES			$
Total Due			$

Payment Methods (Choose One)

Credit Card
Name on card		Billing Zip Code

Card #		Security #

Exp.Date (Month/Year):

Coupon/Voucher

Coupon/Voucher Description

Issued by (MAGIC or other, please specify)

Coupon/Voucher Number (if applicable)

Additional Information

I understand and accept all enrollment conditions*

Parent or Guardian Name*

Date*

*required

Please email me event information and schedule updates.

Submitting this registration for classes acknowledges acceptance of all enrollment conditions, payment, refund and insurance policies at 74th St. MAGIC.

Please fill out the form below and submit. One of our MAGIC team members will contact you shortly to confirm course availability.

Previously enrolled at MAGIC

Yes

Child's name

Birth date

Age

Sex

School and/or current program

Primary Email Address*

* required

Home Address

Apt#

City

State

Zip

Mother's Name

E-mail

Home Phone

Work

Cell

Father's Name

E-mail

Home Phone

Work

Cell

Alternate Address

Emergency Contact

Phone

Cell

Physician's Name

Phone

Participating adult and/or person authorized to pick up child

What's the best way for us to contact you?

Mother's Email

Mother's Phone

Father's Email		Father's Phone
Other

PLEASE CHECK APPROPRIATE BOXES

Does your child take any medications regularly?

Yes

Name of medication, dosage

Condition medication is for

Are there any allergies or health conditions that we should be aware of?

Yes

If yes, please describe

Eyeglasses
(Should they be worn during their lessons?)

Yes

Contact lenses
(Should they be worn during their lessons?)

Yes

Dental Appliances

Yes

If yes, please describe

Hearing Aids

Yes

Please list any physical conditions we should be aware of

CLASS INFORMATION

Age Group

		MAGIC MAKERS, 6-18 months
		MAGIC MAKERS, 18-26 months
		MAGIC MAKERS, 2-3.5 Years
		MAGIC KIDS, 3-8 Years

Name of Class

Name of Additional Class

PAYMENT INFORMATION

Class	Day	Time	Fee
All MAGIC Classes MAGIC Classes, First Class Per Week MAGIC Classes, Additional Class Per Week			$ $
Drop-in Class (D) Month /Day			$

Total Due			$

Payment Methods (Choose One)

Credit Card
Name on card		Billing Zip Code

Card #		Security #

Exp.Date (Month/Year):

Coupon/Voucher

Coupon/Voucher Description

Issued by (MAGIC or other, please specify)

Coupon/Voucher Number (if applicable)

Additional Information

I understand and accept all enrollment conditions*

Parent or Guardian Name*

Date*

*required

Please email me event information and schedule updates.

Submitting this registration for classes acknowledges acceptance of all enrollment conditions, payment, refund and insurance policies at 74th St. MAGIC.